| NPI | 1720632854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OH PT022324) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT006605) |
| Enumeration Date | 2019-07-26 |
| Last Update Date | 2026-05-11 |