Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | CT 001614 | CT |
NPI | 1093176141 |
---|---|
Provider Name | Mrs. Kathleen G Domek |
First Address | West Haven, CT 06516-7054 |
Second Address | Stratford, CT 06614 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2016 |
Last Update Date | 17/03/2016 |