| NPI | 1336651207 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANEADA VANCOL Owner 772-501-6619 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD1600X Clinic/Center Developmental Disabilities |
| Additional Taxonomies | 261QD1600X Clinic/Center Developmental Disabilities |
| Enumeration Date | 2017-10-31 |
| Last Update Date | 2024-07-12 |