| NPI | 1346880341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320700000X Residential Treatment Facility, Physical Disabilities (Licence: IN 21015321) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: IN 27060564A) |
| 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: IN 21015321) | |
| Enumeration Date | 2020-01-08 |
| Last Update Date | 2024-02-28 |