| NPI | 1811585938 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CAROL ANN WILLARD Provider Enrollment Administrator 907-543-6452 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2021-01-05 |