Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1053697441 |
---|---|
Provider Name | Mr. Marlon Gerrick Mitchell |
First Address | Gardena, CA 90248-3523 |
Second Address | Gardena, CA 90248-3523 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2011 |
Last Update Date | 25/02/2014 |