| Name | Value |
|---|---|
| PROVIDER TYPE | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| CLASSIFICATION | Intern, Physical Therapist |
| STATUS | Active |
| VA CODE | V130817 |
| X12 CODE | 390200000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5330408 |
| EFFECTIVE DATE/TIME |
|