| NPI | 1467683805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: VA CPED3170) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment |
| 335E00000X Prosthetic/Orthotic Supplier | |
| 225000000X Orthotic Fitter | |
| Enumeration Date | 2009-08-03 |
| Last Update Date | 2011-02-04 |