Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | GA001342 | GA |
Y | 156FX1800X | Optician | GA001342 | GA |
NPI | 1790059160 |
---|---|
Provider Name | Mr. Lee Cook |
First Address | Atlanta, GA 30309-1413 |
Second Address | Atlanta, GA 30309-1413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2012 |
Last Update Date | 02/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
GA001342 | LICENSED DISPENSING OPTICIAN (01) | GA |