Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1101004032 | VA |
NPI | 1083088082 |
---|---|
Provider Name | Mr. Gus Singleton JR. |
First Address | Newport News, VA 23608-5122 |
Second Address | Hampton, VA 23666-1787 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2015 |
Last Update Date | 14/11/2015 |