| NPI | 1992369102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 3104A0625X Assisted Living Facility, Assisted Living, Mental Illness |
| Additional Taxonomies | 310400000X Assisted Living Facility |
| 311ZA0620X Custodial Care Facility, Adult Care Home | |
| Enumeration Date | 2019-04-24 |
| Last Update Date | 2019-04-24 |