Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath |
NPI | 1104255843 |
---|---|
Provider Name | Annex Luberisse |
First Address | Marshall, MO 65340-3365 |
Second Address | Marshall, MO 65340-3365 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2013 |
Last Update Date | 04/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1710320643 | NPI (01) | |
MA4558 | PTAN (01) |