Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1053510784 |
---|---|
Provider Name | Scott Wimberly |
First Address | Culver City, CA 90232-2716 |
Second Address | Culver City, CA 90232-2716 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2007 |
Last Update Date | 12/07/2007 |