| NPI | 1396927422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 524-01-001) |
| Enumeration Date | 2007-11-30 |
| Last Update Date | 2007-11-30 |