| NPI | 1083918528 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TATIA P JACKSON Excutive Director 414-732-8636 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service |
| Additional Taxonomies | 251S00000X |
| Enumeration Date | 2010-12-24 |
| Last Update Date | 2010-12-24 |