NPI | 1790105617 |
---|---|
Entity Type | Organization |
Authorized Contact | CHERYL A COLWELL Owner/Operator 618-392-8255 |
Organization Subpart ? | No |
Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: IL 180005996) |
Enumeration Date | 2014-04-17 |
Last Update Date | 2014-04-17 |