| NPI | 1578954350 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ELAINA MANUELE Co Manager 662-417-5475 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QA0401X Family Medicine Addiction Medicine (Licence: TN 37386) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TN 35420) |
| Enumeration Date | 2015-02-14 |
| Last Update Date | 2015-02-20 |