| NPI | 1760253025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: MD 28806) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 28806) |
| Enumeration Date | 2024-01-15 |
| Last Update Date | 2025-10-01 |