| NPI | 1437389665 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER MARIE GILDEHAUS-BALLEYDIER Owner 636-390-0047 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2009-07-22 |
| Last Update Date | 2009-07-22 |