| NPI | 1356554372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320700000X Residential Treatment Facility, Physical Disabilities (Licence: PR 12401) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 12401) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2022-06-20 |