Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1154599736 |
---|---|
Provider Name | Mr. Mike Earl Butaud |
First Address | Jasper, TX 75951 |
Second Address | Jasper, TX 75951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2008 |
Last Update Date | 15/02/2008 |