| NPI | 1215452479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501303510) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0013686) |
| Enumeration Date | 2017-08-09 |
| Last Update Date | 2025-02-05 |