| NPI | 1760791511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MO 2010033249) |
| Additional Taxonomies | 225000000X Orthotic Fitter |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2010-09-28 |
| Last Update Date | 2022-07-29 |