| NPI | 1164398350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 376G00000X Nursing Home Administrator (Licence: CA 392701619) |
| Additional Taxonomies | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: CA 6074363740) |
| Enumeration Date | 2025-10-14 |
| Last Update Date | 2025-10-14 |