| NPI | 1164096244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QC1800X Clinic/Center, Corporate Health |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| Enumeration Date | 2021-05-13 |
| Last Update Date | 2021-05-13 |