Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 593 | MT |
NPI | 1013071455 |
---|---|
Provider Name | Todd Erickson |
First Address | Kalispell, MT 59901-4032 |
Second Address | Kalispell, MT 59901-4032 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
048-3769 | (05) | MT |