| NPI | 1104986512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501012395) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NJ 40QA01176100) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2010-08-15 |