| NPI | 1235782814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 252Y00000X Early Intervention Provider Agency (Licence: WY 69611) |
| Additional Taxonomies | 251B00000X Case Management (Licence: WY 69611) |
| 253Z00000X In Home Supportive Care (Licence: WY 69611) | |
| 305R00000X Preferred Provider Organization (Licence: WY 69611) | |
| Enumeration Date | 2019-07-22 |
| Last Update Date | 2019-07-22 |