| NPI | 1750828182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501302556) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 460603799502) |
| Enumeration Date | 2017-01-24 |
| Last Update Date | 2023-03-17 |