Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT1208 | MS |
NPI | 1003239930 |
---|---|
Provider Name | Arthur Davis |
First Address | Ridgeland, MS 39158-1227 |
Second Address | Ridgeland, MS 39157-5128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2014 |
Last Update Date | 29/01/2014 |