| NPI | 1194042515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities (Licence: VA 148) |
| Enumeration Date | 2010-04-24 |
| Last Update Date | 2010-04-24 |