| NPI | 1679624977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: SC 3306) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: WV 859) |
| Enumeration Date | 2007-01-15 |
| Last Update Date | 2008-06-24 |