| NPI | 1609311240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC 16035) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 25749) |
| Enumeration Date | 2017-01-05 |
| Last Update Date | 2017-01-05 |