Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 02-04-05-025 | WI |
NPI | 1982901765 |
---|---|
Provider Name | Mr. Richard Spenner SR. |
First Address | Port Washington, WI 53074-1765 |
Second Address | Port Washington, WI 53074-1765 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2011 |
Last Update Date | 14/02/2011 |