| NPI | 1770982514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CA 508124013) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: CA AT 3266) |
| Enumeration Date | 2014-08-18 |
| Last Update Date | 2014-08-18 |