Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 5501011168 | MI |
NPI | 1457857005 |
---|---|
Provider Name | Daniel Wolocko |
First Address | Livonia, MI 48150-5011 |
Second Address | Livonia, MI 48154-1971 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2018 |
Last Update Date | 03/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5501011168 | (05) | MI |