| NPI | 1306205562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: GA MT001916) |
| Additional Taxonomies | 171W00000X Contractor (Licence: AL Massage 1666) |
| Enumeration Date | 2016-02-16 |
| Last Update Date | 2016-02-16 |