Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | 1499 | AL |
NPI | 1154405546 |
---|---|
Provider Name | Mr. John T Bush |
First Address | Northport, AL 35476-3374 |
Second Address | Northport, AL 35476-3374 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
510 70415 | BC/BS (01) | AL |