Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1790887537 |
---|---|
Provider Name | Mr. David Polak |
First Address | Warrenville, IL 60555-1249 |
Second Address | Chicago, IL 60612-3728 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 08/07/2007 |