| NPI | 1275201022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility |
| Additional Taxonomies | 2084P0802X Psychiatry & Neurology, Addiction Psychiatry (Licence: CA tbd) |
| 320800000X Community Based Residential Treatment Facility, Mental Illness (Licence: CA tbd) | |
| Enumeration Date | 2021-09-04 |
| Last Update Date | 2021-09-04 |