Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | IL |
NPI | 1003090309 |
---|---|
Provider Name | Chad Davis |
First Address | New Lenox, IL 60451-2580 |
Second Address | New Lenox, IL 60451-2694 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2007 |
Last Update Date | 21/12/2007 |