| NPI | 1033694633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X Pedorthist (Licence: TX C46789) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2018-09-28 |
| Last Update Date | 2019-10-04 |