NPI | 1255491098 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MD D0044154) |
Additional Taxonomies | 251S00000X Community/Behavioral Health |
Enumeration Date | 2006-12-11 |
Last Update Date | 2021-06-02 |