| NPI | 1912098401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist Orthopedic (Licence: SC 4654) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: SC 4654) |
| 225100000X Physical Therapist (Licence: SC 4654) | |
| 2251S0007X Physical Therapist Sports (Licence: SC 4654) | |
| Enumeration Date | 2006-09-27 |
| Last Update Date | 2016-07-27 |