| NPI | 1790997286 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 2268) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: FL MA 42799) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2007-07-08 |