| NPI | 1184159576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004504) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other |
| Enumeration Date | 2017-04-24 |
| Last Update Date | 2017-09-25 |