Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251G0304X | Physical Therapist - Geriatrics | 5501011421 | MI |
NPI | 1043782121 |
---|---|
Provider Name | Roy Stephen Montemayor |
First Address | Shelby Township, MI 48315-5344 |
Second Address | Shelby Township, MI 48315-5344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2018 |
Last Update Date | 29/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1245235720 | (05) | MI |