| NPI | 1205811312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QC1500X Clinic/Center, Community Health |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: MN 32355) |
| Enumeration Date | 2005-12-12 |
| Last Update Date | 2011-05-12 |