| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
|
| Primary Taxonomy | 261QM2500X Clinic/Center Medical Specialty |
| Additional Taxonomies | 261QH0100X Clinic/Center Health Service |
| 261QM1300X Clinic/Center Multi-Specialty |
| 261QP3300X Clinic/Center Pain |
| 261QR0800X Clinic/Center Recovery Care |
| 261QX0100X Clinic/Center Occupational Medicine |
| 305R00000X Preferred Provider Organization |
| 305S00000X Point of Service |
| 332B00000X Durable Medical Equipment & Medical Supplies |
| 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment |
| 335G00000X Medical Foods Supplier |
| Enumeration Date | 2022-09-20 |
| Last Update Date | 2022-09-20 |