| NPI | 1720365943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: TX 11779) |
| Additional Taxonomies | 111NR0400X (Licence: TX 11779) |
| 111NS0005X Chiropractor, Sports Physician (Licence: TX 11779) | |
| Enumeration Date | 2011-11-16 |
| Last Update Date | 2019-07-31 |