| NPI | 1164619011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MN 4678) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: WI 991-19) |
| Enumeration Date | 2007-09-25 |
| Last Update Date | 2011-04-22 |