Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225700000X | Massage Therapist | 09980-01073 | KS |
N | 226300000X | Kinesiotherapist | YA-34381 | KS |
NPI | 1639494073 |
---|---|
Provider Name | Mr. Darryl L Olive JR. |
First Address | Columbia, MO 65203-2582 |
Second Address | Columbia, MO 65203-2582 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2010 |
Last Update Date | 23/08/2021 |