| NPI | 1700278033 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT 80735864810) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: UT 80735864701) |
| Enumeration Date | 2015-02-24 |
| Last Update Date | 2015-02-24 |