| NPI | 1689066300 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111NS0005X Chiropractor, Sports Physician (Licence: VT 0060001196) |
| Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: VA 0104001779) |
| Enumeration Date | 2015-03-04 |
| Last Update Date | 2015-03-04 |