| NPI | 1417480906 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | UTUMPORN LAOWANSIRI President 314-541-9377 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: FL DN20017) |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2017-04-11 |