| NPI | 1356509061 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELANIE L MICK Medical Credentialing Consultant 234-855-6458 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty |
| Enumeration Date | 2008-05-29 |
| Last Update Date | 2013-06-05 |