| NPI | 1104615046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2025-05-06 |
| Last Update Date | 2025-05-06 |