| NPI | 1750984043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QC1800X Clinic/Center, Corporate Health |
| Additional Taxonomies | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Enumeration Date | 2020-11-18 |
| Last Update Date | 2020-11-18 |