Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1942461629 |
---|---|
Provider Name | Mr. Rickey Earl Goerges |
First Address | San Antonio, TX 78229-3474 |
Second Address | San Antonio, TX 78229-3474 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2008 |
Last Update Date | 24/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0965000001 | (02) | TX |