| NPI | 1205156767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 3104A0625X Assisted Living Facility, Assisted Living, Mental Illness |
| 311ZA0620X Custodial Care Facility, Adult Care Home | |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2010-06-08 |
| Last Update Date | 2014-02-26 |