| NPI | 1508644600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO 0020483) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 050776) |
| 225100000X Physical Therapist (Licence: TN 15337) | |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: AZ LPT-033871) | |
| Enumeration Date | 2023-09-19 |
| Last Update Date | 2025-04-07 |