| NPI | 1740667740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ID 4455) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: UT 5893509-2401) |
| Enumeration Date | 2015-04-29 |
| Last Update Date | 2020-02-06 |