| NPI | 1255912663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: LA A8143) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: LA LA9243) |
| Enumeration Date | 2021-04-16 |
| Last Update Date | 2021-04-16 |