Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | P1026 |
NPI | 1316099187 |
---|---|
Provider Name | Mr. Alexander Johnson |
First Address | Great Barrington, MA 01230-1569 |
Second Address | Pittsfield, MA 01201-4745 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1524631 | (05) | MA |