Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1881619633 |
---|---|
Provider Name | Mr. Robert L Henderlite |
First Address | Charlotte, NC 28262-9746 |
Second Address | Charlotte, NC 28262-9746 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2006 |
Last Update Date | 07/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DE2724 | (05) | SC |
DM0376 | (05) | SC |