| NPI | 1811393622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1259742) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT29602) |
| Enumeration Date | 2014-11-06 |
| Last Update Date | 2019-07-30 |