| NPI | 1982337911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 172V00000X Community Health Worker (Licence: CT 527) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 225700000X Massage Therapist (Licence: RI 02744) | |
| 225700000X Massage Therapist (Licence: CT 29011182) | |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2024-09-14 |