| NPI | 1972053536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: PA 708933) |
| Additional Taxonomies | 171W00000X Contractor (Licence: VA 974938) |
| Enumeration Date | 2016-10-07 |
| Last Update Date | 2016-10-07 |