Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 847 | IL |
NPI | 1194773887 |
---|---|
Provider Name | Mr. John Marvin Mckissick |
First Address | Tuscaloosa, AL 35405-2059 |
Second Address | Tuscaloosa, AL 35404-5015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 08/07/2007 |