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 |