| NPI | 1154392694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: VA 0104555962) |
| Additional Taxonomies | 111NS0005X Chiropractor Sports Physician (Licence: MD 03284) |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2007-07-08 |