| NPI | 1295272623 |
|---|---|
| Former Legal Business Name | SHANA MADALYN WILTZ |
| Entity Type | Organization |
| Authorized Contact | SHANA MADALYN WILTZ CEO 337-376-0473 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: LA 11041986) |
| Enumeration Date | 2017-01-24 |
| Last Update Date | 2017-01-24 |