| NPI | 1215051255 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MT CHI-CHI-LIC-2922) | 
| Additional Taxonomies | 111N00000X Chiropractor (Licence: ID CHIA-1143) | 
| Enumeration Date | 2007-03-16 | 
| Last Update Date | 2023-09-11 |