| NPI | 1053680215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2008018812) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2004014100) |
| Enumeration Date | 2011-12-17 |
| Last Update Date | 2011-12-17 |