| NPI | 1336530674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 2383) |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 2383) |
| Enumeration Date | 2015-02-09 |
| Last Update Date | 2015-02-10 |