| NPI | 1588912307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: NH 17908) |
| Additional Taxonomies | 2085R0001X (Licence: MA 269358) |
| 2085R0001X (Licence: IL 125.061272) | |
| 2085R0001X (Licence: WI 61815-20) | |
| Enumeration Date | 2012-08-28 |
| Last Update Date | 2025-09-23 |