Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 2062 | MS |
NPI | 1619503240 |
---|---|
Provider Name | Johnny Hulbert |
First Address | Hines, IL 60141 |
Second Address | Hines, IL 60141-3030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2020 |
Last Update Date | 16/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000000 | VA (01) | IL |