Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4133-S | OH |
NPI | 1124380860 |
---|---|
Provider Name | Mrs. Michele Costanzo |
First Address | Columbia Station, OH 44028-9594 |
Second Address | Columbia Station, OH 44028-9594 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2012 |
Last Update Date | 08/06/2012 |