| NPI | 1902573868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 108657) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: IA 108657) |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2022-10-20 |