| NPI | 1063905669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0017727) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CO 2000032525) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2021-06-19 |