| NPI | 1760056790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 311ZA0620X Custodial Care Facility, Adult Care Home |
| Enumeration Date | 2021-05-14 |
| Last Update Date | 2024-02-21 |