Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SL6805 | CA |
NPI | 1144852096 |
---|---|
Provider Name | Ray Favela |
First Address | Fullerton, CA 92831-3603 |
Second Address | Fullerton, CA 92831-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2020 |
Last Update Date | 09/02/2020 |