| NPI | 1104266964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP0905X Clinic/Center Public Health, State or Local |
| Additional Taxonomies | 261QC1500X Clinic/Center Community Health |
| 261QM2500X Clinic/Center Medical Specialty | |
| 281P00000X Chronic Disease Hospital | |
| 282N00000X General Acute Care Hospital | |
| Enumeration Date | 2013-06-26 |
| Last Update Date | 2019-06-12 |