| NPI | 1811652951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 302R00000X Health Maintenance Organization (Licence: TX 0563473) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health (Licence: TX 0563473) |
| Enumeration Date | 2021-11-03 |
| Last Update Date | 2022-06-05 |