Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | CA |
NPI | 1013496678 |
---|---|
Provider Name | Mr. Randy D Smart JR. |
First Address | San Luis Obispo, CA 93401-7186 |
Second Address | San Luis Obispo, CA 93401-7186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2018 |
Last Update Date | 14/08/2018 |