| NPI | 1912667338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: CO ptl.ooo6135) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0006135) |
| Enumeration Date | 2021-12-27 |
| Last Update Date | 2022-01-27 |