Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2254 | OH |
NPI | 1033198452 |
---|---|
Provider Name | Michael Martuccio |
First Address | Warren, OH 44484-2430 |
Second Address | Warren, OH 44484-2430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2006 |
Last Update Date | 11/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0202300 | (05) | OH |
U60064 | (02) | OH |