| NPI | 1649164302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 311ZA0620X Custodial Care Facility, Adult Care Home |
| Additional Taxonomies | 311ZA0620X Custodial Care Facility, Adult Care Home (Licence: WI 18319) |
| Enumeration Date | 2025-06-06 |
| Last Update Date | 2025-06-06 |