| NPI | 1356805873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OH PT020503) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT006680) |
| Enumeration Date | 2019-01-29 |
| Last Update Date | 2023-05-24 |