| NPI | 1003247891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501016584) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0012446) |
| Enumeration Date | 2013-12-05 |
| Last Update Date | 2014-11-07 |