Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1013006188 |
---|---|
Provider Name | Robert Brodhead |
First Address | Los Angeles, CA 90015-3023 |
Second Address | Los Angeles, CA 90015-3023 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |