| NPI | 1538653480 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JACQUE KEIL Credentialing Coordinator 866-933-1381 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation |
| Additional Taxonomies | 111N00000X Chiropractor |
| 207R00000X Internal Medicine | |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2018-06-14 |