Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 09833 | LA |
Y | 213ES0000X | Sports Medicine | 09833 | LA |
NPI | 1053824615 |
---|---|
Provider Name | Brittany Dale |
First Address | Covington, LA 70433-8204 |
Second Address | Covington, LA 70433-8204 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5CP75 | MEDICARE (01) | LA |