| NPI | 1861470973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 6953) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 551) |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2014-09-04 |