| NPI | 1205050374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI pending) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2025-09-11 |