| NPI | 1710511357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MO 2020005290) |
| Additional Taxonomies | 111NR0400X (Licence: MO 2020005290) |
| Enumeration Date | 2020-02-22 |
| Last Update Date | 2020-02-22 |