| NPI | 1659769446 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMY MARIE NIEMAN Director Of Credentialing 833-510-4357 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207RA0401X Internal Medicine, Addiction Medicine |
| Additional Taxonomies | 261QM2800X Clinic/Center, Methadone Clinic |
| 261QR0405X Clinic/Center, Rehabilitation, Substance Use Disorder | |
| 291U00000X Clinical Medical Laboratory | |
| Enumeration Date | 2014-12-31 |
| Last Update Date | 2023-10-16 |