Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | PT27871 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT27871 | CA |
NPI | 1003031899 |
---|---|
Provider Name | Anocha Suphol |
First Address | Riverside, CA 92501-4136 |
Second Address | Riverside, CA 92501-4136 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 08/07/2007 |