| 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 |