| NPI | 1396054961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 385H00000X Respite Care |
| 310400000X Assisted Living Facility | |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2010-09-30 |
| Last Update Date | 2023-12-28 |