Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | LP.00116 | OH |
N | 225000000X | Orthotic Fitter | COA00304 |
NPI | 1376007849 |
---|---|
Provider Name | Kevin M Spicer |
First Address | Bolivar, OH 44612-8512 |
Second Address | Bolivar, OH 44612-8512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2019 |
Last Update Date | 31/08/2020 |