| NPI | 1104127844 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LESLIE ANNE SIESS Owner 636-256-0880 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: MO 26-6639) |
| Enumeration Date | 2010-11-11 |
| Last Update Date | 2010-11-11 |