| NPI | 1730597881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NH 3928) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 21527) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2239) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NH 0503) | |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2022-02-03 |