Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1124386438 |
---|---|
Provider Name | Mr. Horace Earl Ferguson JR. |
First Address | Myrtle Beach, SC 29588 |
Second Address | Myrtle Beach, SC 29588 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2012 |
Last Update Date | 25/04/2012 |