| NPI | 1639957277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities (Licence: AZ 221509-14979) |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
| Enumeration Date | 2023-09-15 |
| Last Update Date | 2023-09-15 |