| NPI | 1083031215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 251S00000X Community/Behavioral Health | |
| Enumeration Date | 2014-03-26 |
| Last Update Date | 2017-08-16 |