| NPI | 1780905901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 35.141981) |
| Additional Taxonomies | 2085R0001X (Licence: MI 4301106825) |
| 2085R0001X (Licence: SC LL 32666) | |
| Enumeration Date | 2010-06-22 |
| Last Update Date | 2021-04-16 |