Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 2910 | CO |
NPI | 1003186446 |
---|---|
Provider Name | Justin Ryan Willis |
First Address | Thornton, CO 80241-2932 |
Second Address | Thornton, CO 80241-2932 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2012 |
Last Update Date | 03/01/2012 |