| NPI | 1760961080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 168908) |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility (Licence: OH 165105) |
| Enumeration Date | 2018-08-08 |
| Last Update Date | 2019-06-17 |