| NPI | 1386254530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT015947) |
| Additional Taxonomies | 261QP2000X Clinic/Center Physical Therapy (Licence: LA 10544) |
| Enumeration Date | 2020-08-03 |
| Last Update Date | 2022-07-26 |