Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | CFO02049 | |
Y | 225000000X | Orthotic Fitter | CFTS0684 |
NPI | 1821145400 |
---|---|
Provider Name | Mr. Luther Green Brock JR. |
First Address | Winston Salem, NC 27116-1348 |
Second Address | Winston Salem, NC 27106-3268 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 12/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7795178 | (05) | NC |
7795387 | (05) | NC |