Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 2305005530 | VA |
N | 2251S0007X | Physical Therapist - Sports | 2305005530 | VA |
NPI | 1275662140 |
---|---|
Provider Name | Mr. Greg B Cornforth |
First Address | Abingdon, VA 24210-2314 |
Second Address | Lebanon, VA 24266 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4979711 | (05) | VA |