| NPI | 1538674593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: OH 171929) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 164400) |
| Enumeration Date | 2017-12-12 |
| Last Update Date | 2019-07-29 |