| NPI | 1417204454 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GAVIN THOMAS GUARISCO Owner 985-384-6604 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: LA 837) |
| Enumeration Date | 2012-08-09 |
| Last Update Date | 2012-08-09 |