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Provider NPI: 1275098600

Provider Information:
Gender: M
Sole Proprietor

Practice Location:
9625 NE CHERRY CT  KANSAS CITY, MO 64155-2091 US
Tel: 816-332-5823  Fax: --

Business Mailing Address:
9625 NE CHERRY CT  KANSAS CITY, MO 64155-2091 US
Tel: 816-332-5823  Fax: --

NPI Information:
NPI: 1275098600
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
N175L00000XOther Service Providers
Y172V00000XOther Service Providers
Community Health Worker

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 172V00000X





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