| NPI | 1265618631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: NJ 40QA01269800) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT020292) |
| Enumeration Date | 2008-01-16 |
| Last Update Date | 2016-04-07 |