| NPI | 1700340106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QX0100X Clinic/Center, Occupational Medicine (Licence: MI 5101018005) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MI 5101018005) |
| Enumeration Date | 2019-01-30 |
| Last Update Date | 2026-04-02 |