| NPI | 1457801755 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JAMES RANDOL STOVALL President 815-397-7454 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019026159) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment |
| Enumeration Date | 2016-10-11 |
| Last Update Date | 2016-12-20 |