| NPI | 1760870463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 251C00000X Day Training, Developmentally Disabled Services |
| 251S00000X | |
| Enumeration Date | 2015-01-03 |
| Last Update Date | 2015-01-03 |