| NPI | 1972910453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: NY 050332-01) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2014-07-17 |
| Last Update Date | 2023-05-22 |