| NPI | 1205112083 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LA'SHELL CLARK Administrator 704-258-3846 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: NC MHL0601201) |
| Additional Taxonomies | 251S00000X |
| Enumeration Date | 2011-10-25 |
| Last Update Date | 2019-09-04 |