Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1326534363 |
---|---|
Provider Name | Mrs. Tracie Radford |
First Address | Riverside, CA 92506-2227 |
Second Address | Riverside, CA 92506-2227 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2018 |
Last Update Date | 02/07/2018 |