| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
|
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 324500000X Substance Abuse Rehabilitation Facility |
| 332800000X Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
| 3336M0002X Pharmacy, Mail Order Pharmacy |
| 347E00000X Transportation Broker |
| 373H00000X Day Training/Habilitation Specialist |
| 385H00000X Respite Care |
| 101YM0800X Counselor, Mental Health |
| 172A00000X Driver |
| 261Q00000X Clinic/Center |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder |
| 261QU0200X Clinic/Center, Urgent Care |
| 276400000X Rehabilitation, Substance Use Disorder Unit |
| 310400000X Assisted Living Facility |
| Enumeration Date | 2021-05-23 |
| Last Update Date | 2021-06-12 |