| NPI | 1073158903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 252Y00000X Early Intervention Provider Agency |
| Additional Taxonomies | 225200000X Physical Therapy Assistant |
| 251E00000X Home Health | |
| 261QP2000X Clinic/Center, Physical Therapy | |
| Enumeration Date | 2019-11-14 |
| Last Update Date | 2019-11-14 |