| NPI | 1194009084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 171W00000X Contractor |
| 172V00000X Community Health Worker | |
| Enumeration Date | 2011-10-11 |
| Last Update Date | 2011-10-18 |