| NPI | 1659845691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 3042) |
| Enumeration Date | 2019-01-13 |
| Last Update Date | 2019-01-13 |