Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | C20123 | MD |
NPI | 1457878209 |
---|---|
Provider Name | Mr. Randy M Fox |
First Address | Gastonia, NC 28054-7488 |
Second Address | Gastonia, NC 28054-7488 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2017 |
Last Update Date | 23/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1962749838 | (05) | NC |