Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 1001128787 | WI |
NPI | 1437577160 |
---|---|
Provider Name | Mr. Luke James Braden |
First Address | Genoa City, WI 53128-2541 |
Second Address | Genoa City, WI 53128-2541 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2014 |
Last Update Date | 31/03/2014 |