Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2019024300 | MO |
NPI | 1629620893 |
---|---|
Provider Name | Jacob Roland |
First Address | Troy, MO 63379-2822 |
Second Address | Troy, MO 63379-2822 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2019 |
Last Update Date | 09/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2019024300 | PRIVATE INSURANCE (01) | MO |