| NPI | 1851622864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 6355752-4810) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: UT 6355752-4701) |
| Enumeration Date | 2010-01-15 |
| Last Update Date | 2010-01-15 |