Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 2105 | SC |
NPI | 1003020587 |
---|---|
Provider Name | Mr. Ronald Wooten |
First Address | West Union, SC 29696-2518 |
Second Address | West Union, SC 29696-2518 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 24/10/2007 |