| NPI | 1255310363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: AL 14864) |
| Additional Taxonomies | 207L00000X Anesthesiology (Licence: AL 00014864) |
| 207LA0401X Anesthesiology, Addiction Medicine (Licence: AL 14864) | |
| 322D00000X Residential Treatment Facility, Emotionally Disturbed Children (Licence: AL 14864) | |
| 3245S0500X Substance Abuse Rehabilitation Facility, Substance Abuse Treatment, Children (Licence: AL 14864) | |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2018-03-19 |