Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023544855 |
---|---|
Provider Name | Mr. Justin Scott |
First Address | East Lansing, MI 48823-7755 |
Second Address | East Lansing, MI 48823-7755 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2017 |
Last Update Date | 11/05/2017 |