| NPI | 1710022454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 222Z00000X Orthotist |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 000206) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2010-06-08 |