Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | L-030454 | AR |
N | 156FX1800X | Optician | L-981101 | AR |
NPI | 1053643817 |
---|---|
Provider Name | Mr. Mickey Lee Drake I |
First Address | Hot Springs Village, AR 71909-5018 |
Second Address | Hot Springs Village, AR 71909-5018 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2010 |
Last Update Date | 04/02/2010 |