| NPI | 1730899444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225700000X Massage Therapist (Licence: WV 2017-3502) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: MD M06141) |
| 225700000X Massage Therapist (Licence: VA 0019016915) | |
| Enumeration Date | 2022-12-05 |
| Last Update Date | 2022-12-05 |