Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4453 | MA |
NPI | 1033396791 |
---|---|
Provider Name | Mr. Joseph R. Erickson |
First Address | Worcester, MA 01607-1725 |
Second Address | Worcester, MA 01607-1725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2008 |
Last Update Date | 24/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0715794 | (05) | MA |