| NPI | 1154740223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center Physical Therapy (Licence: WV PT003459) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT003459) |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2023-05-30 |