Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 10986PT | AZ |
NPI | 1003215682 |
---|---|
Provider Name | Jeremy Mitchell |
First Address | Camarillo, CA 93012-7775 |
Second Address | Lompoc, CA 93436-7027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2014 |
Last Update Date | 19/11/2014 |