Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 2197 | FL |
NPI | 1205950730 |
---|---|
Provider Name | Mr. Keith Barry Smith |
First Address | Indialantic, FL 32903 |
Second Address | Indialantic, FL 32903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1008290001 | (02) |