| NPI | 1649295619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 05658) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NE 2465) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2012-06-21 |