| NPI | 1922779974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Additional Taxonomies | 251B00000X Case Management |
| 320700000X Residential Treatment Facility, Physical Disabilities | |
| 320800000X Community Based Residential Treatment Facility, Mental Illness | |
| Enumeration Date | 2021-09-21 |
| Last Update Date | 2021-09-21 |