| NPI | 1467854372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2800X Clinic/Center, Methadone Clinic (Licence: NJ 2000440) |
| Additional Taxonomies | 291U00000X Clinical Medical Laboratory (Licence: NJ 31D2083671) |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2024-04-27 |