| NPI | 1235415910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225700000X Massage Therapist (Licence: WV 2005-1782) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: WV C50152) |
| Enumeration Date | 2011-10-26 |
| Last Update Date | 2013-10-25 |