Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | DR4124 | TX |
Y | 156FX1800X | Optician | DR4124 | TX |
NPI | 1164781803 |
---|---|
Provider Name | Rosa Serrano |
First Address | El Paso, TX 79936-7974 |
Second Address | El Paso, TX 79936-7974 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2012 |
Last Update Date | 15/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
066324701 | (05) | TX |