Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT08100 | AZ |
NPI | 1013247956 |
---|---|
Provider Name | Stephen R Ibach |
First Address | Scottsdale, AZ 85259-4187 |
Second Address | Scottsdale, AZ 85259-4187 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/12/2009 |
Last Update Date | 26/12/2009 |