Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | PT009702 | GA |
NPI | 1316482755 |
---|---|
Provider Name | Mr. Corinthias Burnett |
First Address | Douglasville, GA 30135-1583 |
Second Address | Douglasville, GA 30135-1583 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2016 |
Last Update Date | 20/12/2016 |