| NPI | 1063414464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 768) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IA 00768) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2017-12-04 |