Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 3007-026 | WI |
NPI | 1225276371 |
---|---|
Provider Name | Mr. Randal Gene Bosi |
First Address | Green Bay, WI 54311-7587 |
Second Address | Green Bay, WI 54301-3503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2009 |
Last Update Date | 28/01/2009 |