Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SL4691 | CA |
NPI | 1033386495 |
---|---|
Provider Name | Vyacheslav Samsanovich |
First Address | Tarzana, CA 91356-4162 |
Second Address | Tarzana, CA 91356-4162 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2008 |
Last Update Date | 14/05/2008 |