| NPI | 1871577874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501011816) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: CO 8823) |
| 2251X0800X Physical Therapist Orthopedic (Licence: CO 8823) | |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2007-07-08 |