Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1101 | LA |
NPI | 1164411179 |
---|---|
Provider Name | Dr. Dennis Brian Mutell |
First Address | Covington, LA 70433-2985 |
Second Address | Covington, LA 70433-2985 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2005 |
Last Update Date | 10/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T52552 | (02) | LA |