| NPI | 1689670580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 35.093044) |
| Additional Taxonomies | 2085R0001X (Licence: MI 4301093974) |
| 2085R0001X (Licence: NY 002001) | |
| Enumeration Date | 2005-06-24 |
| Last Update Date | 2025-04-23 |