| NPI | 1013315712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: UT 9058233-2401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 13320) |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: AZ 13320) | |
| Enumeration Date | 2014-12-11 |
| Last Update Date | 2023-01-08 |