Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 001544 | CT |
NPI | 1225486616 |
---|---|
Provider Name | Mrs. Elizabeth Bergeron |
First Address | Southington, CT 06489-1915 |
Second Address | Southington, CT 06489-1915 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2016 |
Last Update Date | 26/05/2016 |