| NPI | 1144816018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2020-12-15 |
| Last Update Date | 2020-12-15 |