| NPI | 1669413886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO R6098) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: MO R6098) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2022-07-21 |