| NPI | 1124829957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 13095) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MI 5501303701) |
| Enumeration Date | 2025-03-19 |
| Last Update Date | 2026-03-29 |