| NPI | 1568834679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0012992) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1083764) |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2015-10-28 |