Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156F00000X | Technician/Technologist |
NPI | 1124661665 |
---|---|
Provider Name | Mr. Roland Wayne Coulter III |
First Address | Lansing, MI 48910-8232 |
Second Address | Lansing, MI 48910-8232 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2019 |
Last Update Date | 28/10/2019 |