| NPI | 1174050371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 315P00000X Intermediate Care Facility, Intellectual Disabilities |
| Additional Taxonomies | 310500000X Intermediate Care Facility, Mental Illness |
| Enumeration Date | 2017-05-18 |
| Last Update Date | 2021-05-10 |