NPI | 1144382110 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 261QV0200X Clinic/Center, VA (Licence: PR 12851) |
Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PR 12851) |
Enumeration Date | 2006-12-15 |
Last Update Date | 2015-05-12 |