Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 107400 | MO |
NPI | 1427060250 |
---|---|
Provider Name | Mr. Herbert Jones Haman |
First Address | Bolivar, MO 65613-2897 |
Second Address | Bolivar, MO 65613-2897 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PENDING | (05) | MO |