Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0801X | Contact Lens Fitter | 156379 | MI |
Y | 156FX1800X | Optician | 156379 | MI |
NPI | 1366833865 |
---|---|
Provider Name | Mrs. Brandy Peterson |
First Address | Three Rivers, MI 49093 |
Second Address | Three Rivers, MI 49093 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2015 |
Last Update Date | 05/02/2015 |