Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1124197538 |
---|---|
Provider Name | Rebekah Yvonne Bradtke |
First Address | Dyersville, IA 52040-2416 |
Second Address | Dyersville, IA 52040-2416 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0449512 | (05) | IA |