Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 0434 | NM |
NPI | 1003082603 |
---|---|
Provider Name | Mr. Milton James Wilson |
First Address | Albuquerque, NM 87107-3371 |
Second Address | Albuquerque, NM 87110-1648 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2008 |
Last Update Date | 02/05/2008 |