| 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 |