Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 2729202 | MN |
NPI | 1013187855 |
---|---|
Provider Name | Mr. John Peter Vorderbruggen |
First Address | Duluth, MN 55806-1244 |
Second Address | Duluth, MN 55806-1244 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2008 |
Last Update Date | 07/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2100074 | ALLINA MEDICA (01) | MN |