Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist |
NPI | 1215039003 |
---|---|
Provider Name | Mr. John Edwin Allen |
First Address | Lake Villa, IL 60046-8669 |
Second Address | Lake Villa, IL 60046-8669 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 12/12/2011 |