| NPI | 1942685680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: GA PTO16459) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: TX 2113008) |
| Enumeration Date | 2015-07-23 |
| Last Update Date | 2023-02-28 |