| NPI | 1568241834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2023038583) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: MO 2007004680) |
| Enumeration Date | 2023-09-26 |
| Last Update Date | 2023-12-04 |