| NPI | 1245423946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: CA C27618) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: CA C276180) |
| Enumeration Date | 2007-08-25 |
| Last Update Date | 2007-08-25 |