| NPI | 1679031447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ LPT-30671) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: MO 2019006569) |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: CA 296422) | |
| Enumeration Date | 2019-03-11 |
| Last Update Date | 2026-05-01 |