| NPI | 1982095014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2023023364) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: MO 2015002047) |
| Enumeration Date | 2015-02-11 |
| Last Update Date | 2024-01-28 |