Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist |
NPI | 1003317207 |
---|---|
Provider Name | Laura Diver |
First Address | Benzonia, MI 49616-8633 |
Second Address | Benzonia, MI 49616-8633 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2018 |
Last Update Date | 22/02/2018 |