| NPI | 1790343804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320800000X Community Based Residential Treatment Facility, Mental Illness |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| 3104A0625X Assisted Living Facility, Assisted Living, Mental Illness | |
| Enumeration Date | 2019-06-04 |
| Last Update Date | 2019-06-04 |