| NPI | 1740684661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 11687) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: SC 1630) |
| Enumeration Date | 2014-10-21 |
| Last Update Date | 2023-01-31 |