| NPI | 1679348262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 261QR0400X Clinic/Center, Rehabilitation |
| Enumeration Date | 2023-11-24 |
| Last Update Date | 2025-04-06 |