| NPI | 1225157423 |
|---|---|
| Former Name | MICHAEL LOUIS PROVENZANO |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 18057) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: MA 2154) |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2023-10-30 |