| NPI | 1982199394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 4256) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0015755) |
| 225100000X Physical Therapist (Licence: TX 1323881) | |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: WI 14239-24) | |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2023-03-15 |