| NPI | 1073732541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: LA 015129) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: LA 15129) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2019-06-25 |