Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | CL 70 | CA |
N | 156FX1800X | Optician | D-602 | CA |
NPI | 1154488427 |
---|---|
Provider Name | Mr. Ted Wayne Heskett JR. |
First Address | San Francisco, CA 94102-1111 |
Second Address | San Francisco, CA 94102-1111 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 08/07/2007 |