| NPI | 1164181368 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRENDA VANDERPOOL Contract Manager 937-771-6501 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty |
| Enumeration Date | 2021-12-15 |
| Last Update Date | 2021-12-15 |