| NPI | 1265657001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ID PT-322) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-004) |
| Enumeration Date | 2007-04-16 |
| Last Update Date | 2007-07-09 |