| NPI | 1053650531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: OR 5123) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: MN 5605) |
| Enumeration Date | 2013-02-04 |
| Last Update Date | 2022-09-09 |