| NPI | 1184025298 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELLE MCDONALD Independent Medicaid Provider 614-260-5444 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: OH 401224260411) |
| Enumeration Date | 2014-09-08 |
| Last Update Date | 2014-09-08 |