Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1841321478 |
---|---|
Provider Name | Mr. John A Kennedy |
First Address | Tustin, CA 92780-3668 |
Second Address | Tustin, CA 92780-3668 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2007 |
Last Update Date | 01/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DXX00009F | (05) | CA |