| NPI | 1154638021 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LAVERNE BROOMFIELD Cota 217-787-9600 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: IL 057003241) |
| Enumeration Date | 2010-09-13 |
| Last Update Date | 2010-09-13 |