Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4228 | MA |
NPI | 1225255995 |
---|---|
Provider Name | Mr. Samuel Polanco |
First Address | Lawrence, MA 01840 |
Second Address | Lawrence, MA 01840 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1526014 | (05) | MA |