| NPI | 1083768816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: NC MHL-067-143) |
| Additional Taxonomies | 385H00000X Respite Care (Licence: NC MHL-067-143) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2007-07-09 |