| NPI | 1033696869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 251S00000X |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2018-07-24 |