| NPI | 1194223057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 001066) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: CT 2185) |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2021-03-09 |