| NPI | 1306442678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 323P00000X Psychiatric Residential Treatment Facility |
| Enumeration Date | 2020-12-10 |
| Last Update Date | 2023-01-06 |