| NPI | 1205020682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center Physical Therapy (Licence: WI PT2066) |
| Additional Taxonomies | 261QP2000X Clinic/Center Physical Therapy (Licence: FL PT 5290) |
| Enumeration Date | 2007-08-29 |
| Last Update Date | 2021-05-05 |