| NPI | 1215328885 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TJODE MICKELSON Owner 314-398-5800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: IA 06906) |
| Enumeration Date | 2015-02-18 |
| Last Update Date | 2015-02-18 |