Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH0007470 | FL |
NPI | 1497791172 |
---|---|
Provider Name | Mr. Charles Wesley Rice |
First Address | Tampa, FL 33618-2405 |
Second Address | Tampa, FL 33618-2405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
55693 | BLUE CROSS BLUE SHIELD (01) | FL |
U77885 | (02) | FL |