| NPI | 1871148171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320600000X Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 251S00000X |
| 253J00000X Foster Care Agency | |
| Enumeration Date | 2019-08-05 |
| Last Update Date | 2019-08-05 |