| NPI | 1285308247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225800000X Recreation Therapist |
| Enumeration Date | 2021-08-04 |
| Last Update Date | 2021-08-05 |