| NPI | 1255957502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0401X Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) (Licence: NV NV20201768213) |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2020-06-23 |