| NPI | 1396127411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QS1000X Clinic/Center, Student Health |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901021602) |
| Enumeration Date | 2015-06-25 |
| Last Update Date | 2017-06-17 |