| NPI | 1700670320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: ZZ 171000000) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2025-04-08 |
| Last Update Date | 2025-08-27 |