| NPI | 1801180740 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 225000000X Orthotic Fitter (Licence: NJ C53544) | 
| Additional Taxonomies | 111N00000X Chiropractor (Licence: NJ mc03636) | 
| Enumeration Date | 2011-06-08 | 
| Last Update Date | 2024-02-11 |