| NPI | 1124241682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 3245S0500X Substance Abuse Rehabilitation Facility, Substance Abuse Treatment, Children (Licence: SD SD0706) |
| Enumeration Date | 2007-04-11 |
| Last Update Date | 2007-07-08 |