| NPI | 1114913316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 069902432) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: CT 000272) |
| Enumeration Date | 2005-09-22 |
| Last Update Date | 2007-07-08 |