| NPI | 1003787565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 172V00000X Community Health Worker |
| Additional Taxonomies | 251T00000X PACE Provider Organization |
| 320700000X Residential Treatment Facility, Physical Disabilities | |
| Enumeration Date | 2025-09-16 |
| Last Update Date | 2025-09-16 |