| NPI | 1922754118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder (Licence: AR 261QR0405X) |
| Additional Taxonomies | 261QM0801X (Licence: NC 261QR0405X) |
| Enumeration Date | 2022-02-25 |
| Last Update Date | 2022-02-25 |