Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 31TD00367900 | NJ |
NPI | 1205122520 |
---|---|
Provider Name | Vesta Kim |
First Address | East Brunswick, NJ 08816-5808 |
Second Address | East Brunswick, NJ 08816-5808 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2011 |
Last Update Date | 07/07/2011 |