| NPI | 1912299280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: MO 2011022443) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: IL 038011898) |
| Enumeration Date | 2011-05-05 |
| Last Update Date | 2018-05-01 |