| NPI | 1720744345 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGIE MATTINGLY Provider Enrollment Manager 502-630-7425 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2021-11-09 |
| Last Update Date | 2021-11-09 |