| NPI | 1548472491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: CA C41874) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: CA AW322549) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2008-07-16 |