Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1205821378 |
---|---|
Provider Name | Mr. John Satterburg |
First Address | Manitowoc, WI 54221-1900 |
Second Address | Manitowoc, WI 54220-9341 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2005 |
Last Update Date | 22/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38431000 | (05) | WI |