| NPI | 1124583349 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LAWRENCE MACK Owner 210-802-4695 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Additional Taxonomies | 133V00000X Dietitian, Registered |
| Enumeration Date | 2019-02-01 |
| Last Update Date | 2024-08-19 |