| NPI | 1457761405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.003575) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: IL 060495082) |
| Enumeration Date | 2014-04-30 |
| Last Update Date | 2014-04-30 |