Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 138616 | AL |
NPI | 1164934360 |
---|---|
Provider Name | Mr. Grady W Stone JR. |
First Address | Phenix City, AL 36867-3624 |
Second Address | Phenix City, AL 36867-3624 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2017 |
Last Update Date | 15/04/2020 |