| NPI | 1912059643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MI 5501010772) |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2007-07-08 |