| NPI | 1073638516 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CINDY S PARKER Regional Coordinator 318-636-0390 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: LA 11882) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2020-08-22 |