| NPI | 1669246674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QA0600X Clinic/Center, Adult Day Care |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| 261QD1600X Clinic/Center, Developmental Disabilities | |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| Enumeration Date | 2023-11-09 |
| Last Update Date | 2023-11-09 |