| NPI | 1194054007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-00392) |
| Additional Taxonomies | 133N00000X Nutritionist |
| Enumeration Date | 2009-12-24 |
| Last Update Date | 2009-12-24 |