| NPI | 1801488655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QH0100X Clinic/Center, Health Services |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2021-02-03 |
| Last Update Date | 2021-02-23 |