| NPI | 1679164255 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RUSSELL S RANALLO Secretary 270-417-4813 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine |
| Additional Taxonomies | 2081P2900X Physical Medicine & Rehabilitation Pain Medicine |
| 207Q00000X Family Medicine | |
| Enumeration Date | 2021-01-27 |
| Last Update Date | 2024-08-19 |