| NPI | 1912207382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501004711) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT 25584) |
| Enumeration Date | 2010-11-01 |
| Last Update Date | 2014-11-12 |