Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | 5655 | MA |
Y | 156FX1800X | Optician | 5655 | MA |
NPI | 1811125164 |
---|---|
Provider Name | Mr. Kevin J. Crenshaw |
First Address | Springfield, MA 01107 |
Second Address | Springfield, MA 01107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2009 |
Last Update Date | 25/06/2009 |