| NPI | 1407420185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1346492) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy |
| Enumeration Date | 2021-05-17 |
| Last Update Date | 2025-09-03 |