| NPI | 1295159812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: NY 012494) |
| Additional Taxonomies | 111NS0005X Chiropractor Sports Physician (Licence: NY 012494) |
| Enumeration Date | 2014-02-18 |
| Last Update Date | 2021-05-20 |