| NPI | 1407944077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: IA 06749) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IA 00363) |
| 225700000X Massage Therapist (Licence: IA 02340) | |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2012-08-02 |