| NPI | 1639824220 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TAMMIE WILSON Direct Care Provider 904-686-5121 |
| Organization Subpart ? | No |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2022-02-13 |
| Last Update Date | 2022-02-13 |