Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1801459946 |
---|---|
Provider Name | Mr. Brandon Ellis |
First Address | Hattiesburg, MS 39401-9754 |
Second Address | Hattiesburg, MS 39401-9754 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2019 |
Last Update Date | 15/04/2019 |