| NPI | 1861409302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 5101010362) |
| Additional Taxonomies | 261QM2800X Clinic/Center, Methadone Clinic (Licence: MI 5101010362) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2026-08-27 |