| NPI | 1649573676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 222Z00000X Orthotist (Licence: VA 2255) |
| Additional Taxonomies | 224L00000X (Licence: VA 0675) |
| 225000000X Orthotic Fitter (Licence: VA 2255) | |
| Enumeration Date | 2010-12-14 |
| Last Update Date | 2010-12-14 |