| NPI | 1871486498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| 261QS0132X Clinic/Center, Ophthalmologic Surgery | |
| Enumeration Date | 2025-06-02 |
| Last Update Date | 2025-06-02 |