Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DIO-397 | HI |
NPI | 1043621519 |
---|---|
Provider Name | Zack Zimmer |
First Address | Honolulu, HI 96823-3273 |
Second Address | Honolulu, HI 96813-6621 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2014 |
Last Update Date | 18/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
W73879484-01 | STATE TAX ID (01) | HI |