| NPI | 1659819548 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GARY N WILKERSON Counselor 267-258-3894 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: VA 0718000262) |
| Additional Taxonomies | 251S00000X (Licence: DE 0000066) |
| Enumeration Date | 2017-02-10 |
| Last Update Date | 2017-02-10 |