| NPI | 1710129622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: UT 7218960-1202) |
| Additional Taxonomies | 111NR0400X (Licence: UT 7218960-1202) |
| 111NS0005X Chiropractor, Sports Physician (Licence: UT 7218960-1202) | |
| Enumeration Date | 2009-03-24 |
| Last Update Date | 2009-03-24 |