Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1164489191 |
---|---|
Provider Name | Mr. O Boyd Gardo JR. |
First Address | Piedmont, SC 29673-8941 |
Second Address | Anderson, SC 29621-5707 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2006 |
Last Update Date | 12/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DE2711 | (05) | SC |