| NPI | 1639522964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: NM PTA1723) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: NM PTA1723) |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2025-10-19 |