| NPI | 1639446172 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANZHELA ANDREICHYK Lpn 262-942-8484 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: WI 307458-31) |
| Enumeration Date | 2011-11-29 |
| Last Update Date | 2011-12-07 |