| NPI | 1215554449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 21204) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL 1852) |
| Enumeration Date | 2020-07-04 |
| Last Update Date | 2020-07-04 |