| NPI | 1679819932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QA1903X Clinic/Center, Ambulatory Surgical (Licence: MA 8430) |
| Additional Taxonomies | 313M00000X Nursing Facility/Intermediate Care Facility (Licence: CT 001019) |
| Enumeration Date | 2012-12-13 |
| Last Update Date | 2012-12-13 |