| NPI | 1053082651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1103X Clinic/Center, Military Ambulatory Procedure Visits Operational (Transportable) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2021-09-23 |
| Last Update Date | 2021-09-23 |