| NPI | 1457763500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305208430) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MI 5501014398) |
| Enumeration Date | 2014-05-23 |
| Last Update Date | 2014-05-23 |