Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1497836035 |
---|---|
Provider Name | Mr. James Richard Henthorn |
First Address | Wichita, KS 67211-3002 |
Second Address | Wichita, KS 67211-3002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2006 |
Last Update Date | 28/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100218340A | (05) | KS |
1933222 | FDA (01) |