Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1912404609 |
---|---|
Provider Name | Mr. Erik Kolberg |
First Address | San Diego, CA 92126-4570 |
Second Address | San Diego, CA 92126-4570 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2018 |
Last Update Date | 09/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1164466488 | (05) | CA |