| NPI | 1508492034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1021988) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OK 707) |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: OK 707) | |
| Enumeration Date | 2020-03-16 |
| Last Update Date | 2021-11-08 |