Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 1517 | IL |
NPI | 1043261464 |
---|---|
Provider Name | Mr. Thomas L Nelson |
First Address | Wildwood, IL 60030-1901 |
Second Address | Lake Forest, IL 60045-1282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 08/07/2007 |