| NPI | 1356006480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 101279) |
| Additional Taxonomies | 222Z00000X Orthotist (Licence: TX 1858) |
| Enumeration Date | 2021-11-03 |
| Last Update Date | 2021-11-03 |