Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | B0057567A | MO |
NPI | 1215122304 |
---|---|
Provider Name | Mrs. Mary Melita Crum |
First Address | Florissant, MO 63033-6741 |
Second Address | Florissant, MO 63033-6741 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2007 |
Last Update Date | 23/05/2008 |