| NPI | 1619976263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: WI 3243) |
| Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: WI 3243) |
| 111NX0800X Chiropractor, Orthopedic (Licence: WI 3243) | |
| Enumeration Date | 2005-07-17 |
| Last Update Date | 2008-04-23 |