| NPI | 1851384457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MI 4301066541) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2025-03-03 |