| NPI | 1699120832 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | PATRICIA ANNE MILLER Owner 618-407-1396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: IL 056004907) |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2016-04-25 |