| NPI | 1710411236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 1215) |
| Additional Taxonomies | 405300000X Prevention Professional (Licence: CT 1215) |
| Enumeration Date | 2017-04-12 |
| Last Update Date | 2022-05-23 |