| NPI | 1578736799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 001623-1) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: NY 019227) |
| Enumeration Date | 2008-04-09 |
| Last Update Date | 2008-04-10 |