Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XL0004X | Low Vision | OTT.Z12499 | LA |
NPI | 1558898304 |
---|---|
Provider Name | Mr. Donald Allen Tumbleston JR. |
First Address | Covington, LA 70435-5777 |
Second Address | Covington, LA 70435-5777 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2017 |
Last Update Date | 11/05/2017 |