| NPI | 1134643356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL1418) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: FL PT23678) |
| Enumeration Date | 2017-07-29 |
| Last Update Date | 2017-07-29 |