Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1073885232 |
---|---|
Provider Name | Mr. Christopher Antonini |
First Address | Morgantown, WV 26505-2926 |
Second Address | Charleston, WV 25301-2338 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2012 |
Last Update Date | 06/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
381002299 | (05) | WV |