| NPI | 1639161565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: UT 6193648-1202) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: IA 04844) |
| Enumeration Date | 2005-08-17 |
| Last Update Date | 2007-07-08 |