| NPI | 1861573586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207RA0401X Internal Medicine, Addiction Medicine (Licence: LA 022970) |
| Additional Taxonomies | 261QM2800X Clinic/Center, Methadone Clinic |
| 261QP0905X Clinic/Center, Public Health, State or Local | |
| 324500000X Substance Abuse Rehabilitation Facility (Licence: LA 022970) | |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder | |
| 207V00000X Obstetrics & Gynecology (Licence: LA 022970) | |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2026-08-06 |