| NPI | 1073547857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist Orthopedic (Licence: VA 2305203258) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: VA 0019004823) |
| 174400000X Specialist (Licence: VA 2305203258) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2020-10-07 |