Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 5201006857 | MI |
NPI | 1083185870 |
---|---|
Provider Name | Carlo Nagtalon |
First Address | Canton, MI 48188-1430 |
Second Address | Canton, MI 48188-1430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2018 |
Last Update Date | 06/12/2018 |