| NPI | 1265066625 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TARA LAFOLLETTE Credentialing Representative 309-852-0197 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QR1300X Clinic/Center Rural Health |
| Enumeration Date | 2020-02-25 |
| Last Update Date | 2020-02-25 |