| NPI | 1588210348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 171400000X Health & Wellness Coach |
| 225800000X Recreation Therapist | |
| Enumeration Date | 2019-08-16 |
| Last Update Date | 2022-04-26 |