Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 05008313A | IN |
NPI | 1063853646 |
---|---|
Provider Name | Mr. Edward Raymond Jones JR. |
First Address | Greenwood, IN 46143-9607 |
Second Address | Greenwood, IN 46143-9607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2013 |
Last Update Date | 06/08/2013 |