| NPI | 1164802922 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BETTYJO BIEBERITZ Contract Coordinator 815-756-4875 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: IL 149017667) |
| Enumeration Date | 2015-06-05 |
| Last Update Date | 2015-07-14 |