| NPI | 1386849586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 15647) |
| Additional Taxonomies | 261QM2800X Clinic/Center, Methadone Clinic (Licence: PR 15647) |
| Enumeration Date | 2007-06-18 |
| Last Update Date | 2022-11-04 |