| NPI | 1811508252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 29911) |
| Additional Taxonomies | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| 320700000X Residential Treatment Facility, Physical Disabilities | |
| 343900000X Non-emergency Medical Transport (VAN) | |
| 347C00000X Private Vehicle | |
| Enumeration Date | 2020-08-10 |
| Last Update Date | 2020-08-10 |