| NPI | 1013532829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501302138) |
| Additional Taxonomies | 261QP2000X Clinic/Center Physical Therapy (Licence: MN 11808) |
| Enumeration Date | 2020-06-08 |
| Last Update Date | 2022-08-17 |