NPI | 1205928454 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME65991) |
Enumeration Date | 2006-09-28 |
Last Update Date | 2007-07-08 |