| NPI | 1750475836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: MO 2000143607) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: MO 2000143607) |
| 335E00000X Prosthetic/Orthotic Supplier (Licence: MO 2000143607) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2022-07-21 |