| NPI | 1942780580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X Pedorthist (Licence: TN PED109) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: TN CFO03775) |
| Enumeration Date | 2018-08-14 |
| Last Update Date | 2018-08-14 |