| NPI | 1457187320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 310400000X Assisted Living Facility |
| Additional Taxonomies | 251S00000X |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder | |
| Enumeration Date | 2024-09-09 |
| Last Update Date | 2024-12-28 |