Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 13603 | WI |
Y | 225100000X | Physical Therapist | 05012847A | IN |
NPI | 1043794548 |
---|---|
Provider Name | Cory Sandberg |
First Address | Indianapolis, IN 46237-2220 |
Second Address | Indianapolis, IN 46237-1905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2018 |
Last Update Date | 01/02/2021 |