| NPI | 1578078978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 251C00000X |
| 347C00000X Private Vehicle | |
| Enumeration Date | 2017-12-06 |
| Last Update Date | 2017-12-06 |