| NPI | 1699774794 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LINDA DETHERAGE Insurance & Credentialing 501-778-1113 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: AR C7930) |
| Additional Taxonomies | 174400000X Specialist (Licence: AR C7476) |
| 174400000X Specialist (Licence: AR E-2274) | |
| Enumeration Date | 2005-07-20 |
| Last Update Date | 2013-09-30 |