| NPI | 1679802672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center, Urgent Care (Licence: MN 55306) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: CA g55814) |
| Enumeration Date | 2009-12-22 |
| Last Update Date | 2013-01-18 |