Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | 21171 |
NPI | 1598989535 |
---|---|
Provider Name | Mr. Sam Thomas |
First Address | Mesquite, TX 75150-6306 |
Second Address | Mesquite, TX 75150-6306 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2007 |
Last Update Date | 08/07/2007 |