| NPI | 1962995563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111N00000X Chiropractor (Licence: WI 5401-12) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: GA CHIR009952) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2019-05-15 |