| NPI | 1457054181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171400000X |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: MO XXXXXXXXXXX) |
| 111NS0005X Chiropractor Sports Physician (Licence: MO 0000000000000) | |
| Enumeration Date | 2023-03-22 |
| Last Update Date | 2023-04-23 |