Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist | RBT-19-98556 | IL |
NPI | 1093366940 |
---|---|
Provider Name | Mr. Gary Tyler Neff |
First Address | Duluth, GA 30096-3186 |
Second Address | Duluth, GA 30096-3186 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/09/2019 |
Last Update Date | 28/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RBT-19-98556 | BACB (01) |