| NPI | 1629489141 |
|---|---|
| Other Name | NONE NONE NONE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: FL ME 46522) |
| Additional Taxonomies | 261Q00000X (Licence: FL ME 46522) |
| Enumeration Date | 2014-05-19 |
| Last Update Date | 2014-05-19 |