| NPI | 1215259106 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DARRELL GEORGE PROVINSE L.P.C., N.C.C 314-746-9622 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: MO 2009036114) |
| Enumeration Date | 2010-02-19 |
| Last Update Date | 2010-02-19 |