Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DO-00000549 | WA |
NPI | 1174886220 |
---|---|
Provider Name | Mr. Daniel Adam Ellis |
First Address | Spokane, WA 99205-4757 |
Second Address | Spokane, WA 99205-4757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2012 |
Last Update Date | 22/06/2012 |