Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1053454132 |
---|---|
Provider Name | Mr. Matthew Levi Talley SR. |
First Address | San Bernardino, CA 92404-5351 |
Second Address | San Bernardino, CA 92404-5351 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 08/07/2007 |