| NPI | 1700719549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM1102X Clinic/Center, Military Outpatient Operational (Transportable) Component (Licence: CA 1619439178) |
| Enumeration Date | 2026-06-03 |
| Last Update Date | 2026-06-15 |