Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 2055 | IL |
NPI | 1407474919 |
---|---|
Provider Name | Absalom Blackmon |
First Address | Hines, IL 60141-0171 |
Second Address | Hines, IL 60141-3030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2020 |
Last Update Date | 10/07/2020 |