Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 5201010453 | MI |
NPI | 1225669112 |
---|---|
Provider Name | Jevron Manasan Macalino JR. |
First Address | Warren, MI 48093-3516 |
Second Address | Warren, MI 48093-3516 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2020 |
Last Update Date | 29/01/2020 |