Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225700000X | Massage Therapist | MSG005663 | PA |
NPI | 1013336841 |
---|---|
Provider Name | Kyle Williams |
First Address | Media, PA 19063-2912 |
Second Address | Media, PA 19063-2912 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2014 |
Last Update Date | 30/04/2016 |