Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1639247968 |
---|---|
Provider Name | Mr. James Ellsworth Homer |
First Address | Stella, NC 28582-9741 |
Second Address | Cedar Point, NC 28584-8019 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 10/07/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
048E0 | BLUE CROSS BLUE SHIELD OF NC (01) | NC |
260464169 | TRI-CARE (01) | NC |
7705142 | (05) | NC |