| NPI | 1760884308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 63619) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: OR 63619) |
| Enumeration Date | 2014-09-25 |
| Last Update Date | 2024-09-09 |