| NPI | 1053957456 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WILLIAM TIDWELL Owner/Physician 270-933-2109 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207ND0101X Dermatology, MOHS-Micrographic Surgery |
| Enumeration Date | 2019-11-20 |
| Last Update Date | 2020-03-27 |