| NPI | 1003367202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT15572) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL439) |
| Enumeration Date | 2016-10-23 |
| Last Update Date | 2016-10-23 |