| NPI | 1720439961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: AZ BH4917) |
| Additional Taxonomies | 320800000X Community Based Residential Treatment Facility, Mental Illness (Licence: AZ BH4917) |
| 385H00000X Respite Care (Licence: AZ BH4917) | |
| Enumeration Date | 2016-06-29 |
| Last Update Date | 2024-12-03 |