Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 41068 | CA |
NPI | 1104471994 |
---|---|
Provider Name | Sean Villacrucis |
First Address | Glendale, CA 91204-1504 |
Second Address | Glendale, CA 91204-1504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2019 |
Last Update Date | 07/08/2019 |