| NPI | 1295282960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: OH LPN.120374.MEDS-IV) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2016-09-09 |
| Last Update Date | 2016-09-09 |