Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1235323809 |
---|---|
Provider Name | Mr. Lester Prove |
First Address | Bryan, TX 77802-2691 |
Second Address | Bryan, TX 77802-2691 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2007 |
Last Update Date | 28/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
09779001 | (05) | TX |