| NPI | 1639530603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083S0010X Preventive Medicine Sports Medicine (Licence: IL 096004152) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096.004152) |
| Enumeration Date | 2016-03-17 |
| Last Update Date | 2016-12-08 |