| NPI | 1508367590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IL 070025807) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC P17972) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096003804) | |
| Enumeration Date | 2018-02-24 |
| Last Update Date | 2022-04-20 |