| NPI | 1467526178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: LA 4185R) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: LA AD8213326 DEA) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: LA MD04185R) | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2008-08-06 |