| NPI | 1114065026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: VA 0104001257) |
| Additional Taxonomies | 111NR0400X Chiropractor Rehabilitation (Licence: PA DC005534L) |
| Enumeration Date | 2007-02-02 |
| Last Update Date | 2007-07-08 |