Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist |
NPI | 1407322357 |
---|---|
Provider Name | Michael Stephen Relle |
First Address | Covington, LA 70433-7128 |
Second Address | Covington, LA 70433-7128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2018 |
Last Update Date | 18/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CPO2891 | AMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, AND PEDORTHOTICS (01) | LA |