| NPI | 1467110692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 172A00000X Driver |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: FL L21000489498) |
| Enumeration Date | 2021-12-06 |
| Last Update Date | 2025-11-11 |