| NPI | 1124823794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness (Licence: AZ BH10421) |
| Additional Taxonomies | 385H00000X Respite Care (Licence: AZ BH10421) |
| Enumeration Date | 2025-02-17 |
| Last Update Date | 2025-02-17 |