| NPI | 1720586662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003030) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: VA 0019012885) |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2019-11-18 |