| NPI | 1164912697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer |
| Additional Taxonomies | 172A00000X Driver |
| 225800000X Recreation Therapist | |
| 251C00000X Day Training, Developmentally Disabled Services | |
| 372600000X Adult Companion | |
| Enumeration Date | 2018-05-10 |
| Last Update Date | 2018-12-19 |