| NPI | 1942001722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 311ZA0620X Custodial Care Facility, Adult Care Home |
| Additional Taxonomies | 315P00000X Intermediate Care Facility, Intellectual Disabilities |
| 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| Enumeration Date | 2025-03-19 |
| Last Update Date | 2025-03-19 |