| NPI | 1790187631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO 12654) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM 4487) |
| 225100000X Physical Therapist (Licence: MA 21351) | |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2014-09-23 |