| NPI | 1790556058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist Orthopedic (Licence: CA 25747) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: CA 25747) |
| 261QP2000X Clinic/Center Physical Therapy (Licence: CA 25747) | |
| Enumeration Date | 2024-01-15 |
| Last Update Date | 2024-01-15 |