Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1073947016 |
---|---|
Provider Name | Patrick Takata |
First Address | Wilmette, IL 60091-3050 |
Second Address | Wilmette, IL 60091-3050 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2013 |
Last Update Date | 27/08/2013 |