| NPI | 1346714425 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WAYNE VINCENT KILTHAU Licensee 669-234-3344 |
| Organization Subpart ? | No |
| Primary Taxonomy | 315P00000X Intermediate Care Facility, Intellectual Disabilities |
| Enumeration Date | 2019-01-11 |
| Last Update Date | 2019-01-11 |