| NPI | 1770533705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225700000X Massage Therapist |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: LA 4005) |
| 225700000X Massage Therapist (Licence: MO 2003030459) | |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2021-08-14 |