| NPI | 1770576233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: IL 038009584) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096-001290) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2008-05-30 |