| NPI | 1790529923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD1600X Clinic/Center Developmental Disabilities |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| 261QA0600X Clinic/Center Adult Day Care | |
| 310400000X Assisted Living Facility | |
| Enumeration Date | 2024-06-21 |
| Last Update Date | 2025-08-05 |