| NPI | 1750952958 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRACY RENNA THOMAS Credentialing Manager 104-663-4036 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine |
| Enumeration Date | 2021-07-08 |
| Last Update Date | 2022-07-28 |