| NPI | 1467247395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| Enumeration Date | 2025-04-11 |
| Last Update Date | 2025-04-11 |