| NPI | 1760580906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: CO 2664) |
| Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: IA Certificate #78) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2007-07-09 |