| NPI | 1083375893 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TAKALA FOMOND Owner 224-420-6894 |
| Organization Subpart ? | No |
| Primary Taxonomy | 291U00000X Clinical Medical Laboratory |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse |
| 261Q00000X Clinic/Center | |
| Enumeration Date | 2022-01-04 |
| Last Update Date | 2022-04-27 |