| NPI | 1962853465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC .8242 PT) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: GA PT012367) |
| Enumeration Date | 2016-06-27 |
| Last Update Date | 2016-06-27 |