Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1053373043 |
---|---|
Provider Name | Mr. George R Carlton JR. |
First Address | Sylacauga, AL 35150-2951 |
Second Address | Sylacauga, AL 35150-2951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2006 |
Last Update Date | 04/03/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0656980001 | (02) | AL |
51004040 | BLUE CROSS BLUE SHIELD (01) | AL |