| NPI | 1548549348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001855) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: GA MT007760) |
| Enumeration Date | 2011-08-10 |
| Last Update Date | 2015-05-27 |