| NPI | 1104950534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: CT 000772) |
| Additional Taxonomies | 111NR0400X (Licence: CT 000772) |
| 111NX0800X Chiropractor, Orthopedic (Licence: CT 000772) | |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2007-07-08 |