| NPI | 1376944322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QA0600X Clinic/Center, Adult Day Care |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| 343900000X Non-emergency Medical Transport (VAN) | |
| 347C00000X Private Vehicle | |
| Enumeration Date | 2014-09-09 |
| Last Update Date | 2014-09-09 |