| NPI | 1417386384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111NR0400X (Licence: AL 2411) |
| Additional Taxonomies | 172M00000X Mechanotherapist |
| 1744R1102X Specialist, Research Study | |
| 224L00000X Pedorthist | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2013-11-01 |
| Last Update Date | 2013-11-01 |