| NPI | 1376488924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 311ZA0620X Custodial Care Facility, Adult Care Home |
| Enumeration Date | 2026-04-21 |
| Last Update Date | 2026-04-21 |