| NPI | 1154468247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 013882) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO 4663) |
| 225700000X Massage Therapist (Licence: NY 0183651) | |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2011-07-19 |