| NPI | 1487204939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 253J00000X Foster Care Agency |
| 3104A0630X Assisted Living Facility, Assisted Living, Behavioral Disturbances | |
| 311Z00000X Custodial Care Facility | |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| 385HR2060X Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child | |
| Enumeration Date | 2019-09-17 |
| Last Update Date | 2019-09-17 |