| NPI | 1144413667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 7779) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: AZ MT-05208) |
| Enumeration Date | 2007-08-20 |
| Last Update Date | 2007-08-20 |