| Name | Value |
|---|---|
| PROVIDER TYPE | Other Service Providers |
| CLASSIFICATION | Veterinarian |
| AREA OF SPECIALIZATION | Medical Research |
| STATUS | Inactive |
| DATE INACTIVATED | 2025-04-01 00:00:00 |
| VA CODE | V082001 |
| X12 CODE | 174MM1900X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253224 |
| EFFECTIVE DATE/TIME |
|