| NPI | 1184417560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 17159) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: WI 17159-24) |
| Enumeration Date | 2025-05-27 |
| Last Update Date | 2025-11-17 |