| NPI | 1932643665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: TN 15698) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1957) |
| Enumeration Date | 2016-12-14 |
| Last Update Date | 2024-06-18 |