| NPI | 1205337771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2018-02-21 |
| Last Update Date | 2018-09-26 |