Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter |
NPI | 1831346964 |
---|---|
Provider Name | Clover Marjorie Colonel |
First Address | Burlington, NC 27215-5046 |
Second Address | Burlington, NC 27215-5046 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2008 |
Last Update Date | 25/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7795167 | (05) | NC |