| NPI | 1578712386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: MD 22656) |
| Additional Taxonomies | 171W00000X Contractor (Licence: NY 029464) |
| Enumeration Date | 2008-09-17 |
| Last Update Date | 2008-09-17 |