| NPI | 1184959314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: MD 22361) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM 4073) |
| Enumeration Date | 2009-10-06 |
| Last Update Date | 2015-02-11 |