| NPI | 1417144734 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JANETTA MARTIN Owner 318-556-0043 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: LA 1564761) |
| Additional Taxonomies | 251T00000X PACE Provider Organization (Licence: LA 1564761) |
| Enumeration Date | 2007-10-01 |
| Last Update Date | 2023-09-06 |