Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501015257 | MI |
NPI | 1003120320 |
---|---|
Provider Name | Tyler Donald Bolley |
First Address | Plymouth, MI 48170-4610 |
Second Address | Plymouth, MI 48170-4610 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2010 |
Last Update Date | 28/07/2010 |