| NPI | 1962390278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 3104A0630X Assisted Living Facility, Assisted Living, Behavioral Disturbances | |
| Enumeration Date | 2025-06-25 |
| Last Update Date | 2025-07-13 |