| NPI | 1811063993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111NS0005X Chiropractor, Sports Physician (Licence: WI 2759-012) |
| Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: MI 2301008871) |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2007-07-08 |