| NPI | 1780019810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P18160) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL3472) |
| Enumeration Date | 2013-09-09 |
| Last Update Date | 2019-10-28 |