Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | CPO2516 | CA |
NPI | 1144434622 |
---|---|
Provider Name | Mr. Steven Thomas Vitale |
First Address | Modesto, CA 95350-4163 |
Second Address | Modesto, CA 95350-4163 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
XA0151460 | (05) | CA |