Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0801X | Contact Lens Fitter | C006424-1 | NY |
Y | 156FX1800X | Optician | C006424-1 | NY |
NPI | 1043501927 |
---|---|
Provider Name | Mr. Romeo Velasco Maloco JR. |
First Address | Port Jefferson Station, NY 11776-1104 |
Second Address | Port Jefferson Station, NY 11776-1104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2011 |
Last Update Date | 26/04/2011 |