| NPI | 1922696780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: VA 0104-557713) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 2000040788) |
| Enumeration Date | 2021-01-07 |
| Last Update Date | 2021-12-07 |