Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1225054828 |
---|---|
Provider Name | Steve A Jewett |
First Address | Belle Fourche, SD 57717-1405 |
Second Address | Belle Fourche, SD 57717-1405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
9280613 | (05) | SD |