| NPI | 1578967758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001373) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00200500) |
| Enumeration Date | 2014-10-16 |
| Last Update Date | 2014-10-16 |