Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1255829446 |
---|---|
Provider Name | Christian David Quiles |
First Address | Davenport, FL 33897-6239 |
Second Address | Davenport, FL 33897-3402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2018 |
Last Update Date | 24/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
017577400 | (05) | FL |