Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1154446813 |
---|---|
Provider Name | Mr. Rex Joseph Johnson |
First Address | Baker City, OR 97814-1456 |
Second Address | Baker City, OR 97814-1456 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 29/10/2007 |