| NPI | 1356604722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: HI MAT 9287) |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2012-06-20 |