| NPI | 1053716852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111NS0005X Chiropractor Sports Physician (Licence: UT 12884926-1202) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 12884926-4810) |
| Enumeration Date | 2014-10-23 |
| Last Update Date | 2022-10-11 |