| NPI | 1770061632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1306652) |
| Additional Taxonomies | 261QP2000X Clinic/Center Physical Therapy (Licence: TX 1306652) |
| 208100000X Physical Medicine & Rehabilitation (Licence: TX 1306652) | |
| Enumeration Date | 2018-08-02 |
| Last Update Date | 2023-11-01 |