| NPI | 1295856797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center Physical Therapy (Licence: CT 000938) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: CT 000354) |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2011-09-23 |