| NPI | 1235522673 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DARRELL G PROVINSE President/Executive Director 314-994-9344 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: MO 2003031617) |
| Additional Taxonomies | 251S00000X (Licence: IL 180-001482) |
| Enumeration Date | 2015-03-10 |
| Last Update Date | 2015-03-10 |