Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 6426 | MA |
NPI | 1093104861 |
---|---|
Provider Name | Nickolas R Willette |
First Address | Fall River, MA 02723-2719 |
Second Address | Fall River, MA 02723-2719 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2015 |
Last Update Date | 27/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
46-1793649 | TID (01) |