| NPI | 1164021408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MO 2020035077) |
| Additional Taxonomies | 111NS0005X Chiropractor Sports Physician (Licence: MO 2020035077) |
| Enumeration Date | 2020-10-19 |
| Last Update Date | 2021-01-21 |