| NPI | 1568612679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility (Licence: VA 0718000027) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| Enumeration Date | 2008-09-25 |
| Last Update Date | 2008-09-25 |