Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LDO002533 | GA |
NPI | 1144665563 |
---|---|
Provider Name | Vijai Davis |
First Address | Hampton, GA 30228-2186 |
Second Address | Hampton, GA 30228-5502 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2013 |
Last Update Date | 30/04/2013 |