| NPI | 1770049595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501303207) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IN 3630-29-3657) |
| Enumeration Date | 2019-02-17 |
| Last Update Date | 2024-02-08 |