| NPI | 1225316573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: CA A1333354) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2011-08-03 |
| Last Update Date | 2017-02-23 |