Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 1720 | IL |
NPI | 1912009903 |
---|---|
Provider Name | Mr. Leavern Guy |
First Address | Picayune, MS 39466-5436 |
Second Address | Picayune, MS 39466-5436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2006 |
Last Update Date | 08/01/2009 |