| NPI | 1548875073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: HI PT-6214-0) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: FL MA83813) |
| Enumeration Date | 2020-09-11 |
| Last Update Date | 2025-08-13 |