| NPI | 1891829636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: LA 03881R) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: LA 03881R) |
| 225400000X Rehabilitation Practitioner (Licence: LA 03881R) | |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2007-07-08 |