| NPI | 1659766913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501017164) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: MI 5502003805) |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2015-04-03 |