| NPI | 1275737470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 2554) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IA 004086) |
| 335E00000X Prosthetic/Orthotic Supplier (Licence: NE 2554) | |
| Enumeration Date | 2007-06-12 |
| Last Update Date | 2020-06-12 |