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 |