| NPI | 1174150320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: TX V9648) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health |
| Enumeration Date | 2020-03-26 |
| Last Update Date | 2025-10-03 |