| NPI | 1518769504 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | 
| Enumeration Date | 2025-03-27 | 
| Last Update Date | 2025-03-27 |