| NPI | 1255771515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 230500408) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: VA 2305004058) |
| Enumeration Date | 2013-07-01 |
| Last Update Date | 2021-03-03 |