| NPI | 1457694531 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MA 3416) | 
| Additional Taxonomies | 111N00000X Chiropractor (Licence: NY X012339) | 
| Enumeration Date | 2013-03-27 | 
| Last Update Date | 2015-02-22 |