Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | 012.007533 | IL |
NPI | 1215455852 |
---|---|
Provider Name | Bethany Banks |
First Address | North Riveride, IL 60546 |
Second Address | North Riveride, IL 60546 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2017 |
Last Update Date | 04/09/2017 |