Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 070022050 | IL |
NPI | 1003279191 |
---|---|
Provider Name | Kendall Giles |
First Address | Mattoon, IL 61938-9253 |
Second Address | Mattoon, IL 61938-9253 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2016 |
Last Update Date | 05/04/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070022050 | LICENSE (01) | IL |