| NPI | 1285323782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 4190-01-001) |
| Enumeration Date | 2023-05-02 |
| Last Update Date | 2023-05-04 |