Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | CPO-02544 | CA |
N | 222Z00000X | Podiatrist | CPO-02544 | CA |
N | 224P00000X | Prosthetist | CPO-02544 | CA |
NPI | 1225108475 |
---|---|
Provider Name | Mr. Henry Alvin Jennings JR. |
First Address | Riverside, CA 92505-1893 |
Second Address | Riverside, CA 92505-1893 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
GXC000030 | (05) | CA |