| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
|
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Additional Taxonomies | 171WV0202X Contractor Vehicle Modifications |
| 171WH0202X Contractor Home Modifications |
| 390200000X Student in an Organized Health Care Education/Training Program |
| 246YR1600X Specialist/Technologist, Health Information Registered Record Administrator |
| 146D00000X Personal Emergency Response Attendant |
| 261QE0002X Clinic/Center Emergency Care |
| Enumeration Date | 2016-08-01 |
| Last Update Date | 2016-08-16 |