| NPI | 1164950929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 320700000X Residential Treatment Facility, Physical Disabilities |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| Enumeration Date | 2017-05-24 |
| Last Update Date | 2017-05-24 |