| NPI | 1790002228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085N0700X (Licence: NJ 25MB08779900) |
| Additional Taxonomies | 2085N0700X (Licence: NY 262553) |
| 2085N0700X (Licence: CT 050166) | |
| Enumeration Date | 2010-04-23 |
| Last Update Date | 2020-03-03 |