Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1862 | TN |
NPI | 1154534048 |
---|---|
Provider Name | Mr. Russell Jeffrey Bridges |
First Address | Ringgold, GA 30736-6826 |
Second Address | Chattanooga, TN 37421 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 08/07/2007 |