Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1101000947 | VA |
NPI | 1225236656 |
---|---|
Provider Name | Mr. Monte Dicks |
First Address | Woodstock, VA 22664-1051 |
Second Address | Woodstock, VA 22664-1051 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2007 |
Last Update Date | 08/07/2007 |