Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SC713 | SC |
NPI | 1053553909 |
---|---|
Provider Name | Mr. John B Fowler |
First Address | Murrells Inlet, SC 29576-9401 |
Second Address | Murrells Inlet, SC 29576-9401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2009 |
Last Update Date | 20/03/2012 |