| NPI | 1720453947 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DENISE SMITH Senior Biller/ Exec. Asst. 331-643-5238 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: IL 180.007149) |
| Additional Taxonomies | 251S00000X (Licence: IL 21415) |
| Enumeration Date | 2015-12-14 |
| Last Update Date | 2015-12-14 |