Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1101001190 | VA |
NPI | 1073706404 |
---|---|
Provider Name | Mr. Michael Moore |
First Address | Winchester, VA 22601-4118 |
Second Address | Winchester, VA 22601-4118 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2007 |
Last Update Date | 20/08/2007 |