| NPI | 1639615891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 22789) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CT 10825) |
| Enumeration Date | 2017-01-12 |
| Last Update Date | 2017-01-12 |