Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 2717 | CA |
NPI | 1114089943 |
---|---|
Provider Name | Mr. Kip Mcgooden |
First Address | Aptos, CA 95003-4771 |
Second Address | Aptos, CA 95003-4700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2006 |
Last Update Date | 08/08/2008 |