| NPI | 1104293950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 22262) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1264012) |
| Enumeration Date | 2015-08-27 |
| Last Update Date | 2018-03-17 |