| NPI | 1104172295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: WA PT60287549) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: MN 9100) |
| Enumeration Date | 2012-07-26 |
| Last Update Date | 2012-07-26 |