| NPI | 1790357051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P12095) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 225200000X Physical Therapy Assistant (Licence: NC P12095) | |
| Enumeration Date | 2021-07-15 |
| Last Update Date | 2021-07-15 |