Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1215176714 |
---|---|
Provider Name | Mr. Irving Christopher Tabaka |
First Address | Chelsea, MI 48118-1225 |
Second Address | Chelsea, MI 48118-1225 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2009 |
Last Update Date | 07/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
233109 | NVA (01) | NJ |
540H103600 | BCBS (01) | MI |