| NPI | 1790153039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2015-09-03 |
| Last Update Date | 2015-09-03 |