Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 1982 | MS |
NPI | 1497204739 |
---|---|
Provider Name | Jack Mixon |
First Address | Greenville, SC 29605-4270 |
Second Address | Greenville, SC 29605-4270 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2016 |
Last Update Date | 28/09/2016 |