| NPI | 1932517273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 1073) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: FL MA 46769) |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2014-07-31 |