Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 2000150904 | MO |
N | 2251G0304X | Physical Therapist - Geriatrics | 2000150904 | MO |
NPI | 1154597524 |
---|---|
Provider Name | Mr. John Ross Ray |
First Address | Ozark, MO 65721-9164 |
Second Address | Ozark, MO 65721-9164 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2008 |
Last Update Date | 11/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MA3248001 | (02) | MO |