| NPI | 1780076117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MD S04125) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001383) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005834) | |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2022-04-20 |