| NPI | 1114058641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT28218) |
| Additional Taxonomies | 171W00000X Contractor (Licence: MI 5501012742) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2023-06-21 |