| NPI | 1063599462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MO 004747) |
| Additional Taxonomies | 247200000X Technician, Other (Licence: MO 9177913995) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2014-02-17 |