Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1700X | Ocularist |
NPI | 1417236860 |
---|---|
Provider Name | Mr. Michael Kaczkowski |
First Address | Little Rock, AR 72205-5528 |
Second Address | Little Rock, AR 72205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2011 |
Last Update Date | 19/09/2018 |