Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1700125820 |
---|---|
Provider Name | Charles Edward Wyatt JR. |
First Address | Tuscaloosa, AL 35404-5015 |
Second Address | Tuscaloosa, AL 35404-5015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2013 |
Last Update Date | 08/02/2013 |