Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | CT0648 | CT |
NPI | 1083877492 |
---|---|
Provider Name | Mr. Edward Broderick |
First Address | Enfield, CT 06082-3890 |
Second Address | Enfield, CT 06082-3890 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2008 |
Last Update Date | 07/07/2008 |