| NPI | 1386200889 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NICOLE HAVRILLA Board President 806-220-6455 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 208000000X Pediatrics |
| Enumeration Date | 2019-05-10 |
| Last Update Date | 2022-06-10 |