| NPI | 1164201679 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGIE MATTINGLY Mgr Provider Enrollment 502-420-2512 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QR0400X Clinic/Center, Rehabilitation |
| Enumeration Date | 2023-09-25 |
| Last Update Date | 2023-09-25 |