| NPI | 1104225564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0013103) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT29629) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2015-03-20 |