Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 070007758 | IL |
NPI | 1164780185 |
---|---|
Provider Name | Jimmy Dapog |
First Address | Litchfield, IL 62056-1552 |
Second Address | Litchfield, IL 62056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2012 |
Last Update Date | 27/04/2012 |