| NPI | 1639396567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305003228) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy |
| Enumeration Date | 2007-04-20 |
| Last Update Date | 2023-08-31 |