| NPI | 1760934905 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHERRY CLEMONS Owner 314-801-8651 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: MO 251E00000X) |
| Enumeration Date | 2016-11-03 |
| Last Update Date | 2016-11-03 |