Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics |
NPI | 1245476902 |
---|---|
Provider Name | C Jones |
First Address | Laurel, MD 20723-1454 |
Second Address | Sweeny, TX 77480-3400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/12/2008 |
Last Update Date | 10/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1952422412 | (02) | TX |
1952422412 | (05) | TX |