| NPI | 1972661130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 111NS0005X Chiropractor, Sports Physician (Licence: MN 4582) |
| Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: SD 979) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1803) | |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2007-07-08 |