| NPI | 1336400886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305205659) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MI 5501012722) |
| Enumeration Date | 2012-05-31 |
| Last Update Date | 2020-02-05 |