| NPI | 1316008204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 335E00000X Prosthetic/Orthotic Supplier (Licence: MS 335E00000X) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: MS 332B00000X) |
| 335E00000X Prosthetic/Orthotic Supplier (Licence: TN PRO0000000069) | |
| 335E00000X Prosthetic/Orthotic Supplier (Licence: TN ORT0000000093) | |
| 335E00000X Prosthetic/Orthotic Supplier (Licence: TX 1829) | |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2017-04-21 |