| NPI | 1386848539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X (Licence: TX 82A) |
| Additional Taxonomies | 171W00000X Contractor |
| 171W00000X Contractor (Licence: TX 82A) | |
| 251S00000X | |
| 261QC1500X Clinic/Center, Community Health (Licence: TX 82A) | |
| Enumeration Date | 2007-06-12 |
| Last Update Date | 2019-03-11 |