| NPI | 1730794603 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DWAYNE LAMONT WILSON Owner 757-636-0884 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251C00000X |
| Additional Taxonomies | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2020-09-09 |
| Last Update Date | 2021-07-14 |