| NPI | 1346952660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251C00000X |
| Additional Taxonomies | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| 385HR2060X Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child | |
| Enumeration Date | 2022-12-19 |
| Last Update Date | 2022-12-19 |