| NPI | 1649518762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X (Licence: MN CPed3494) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: MN CPed3494) |
| Enumeration Date | 2013-01-24 |
| Last Update Date | 2018-03-17 |