| NPI | 1629090782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: FL ISW 1897) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2007-07-08 |