| NPI | 1821318643 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WALLACE LARAY VINSON Registered Surgical Assistant 931-215-1574 |
| Organization Subpart ? | No |
| Primary Taxonomy | 171W00000X Contractor (Licence: IL 238000232) |
| Additional Taxonomies | 171W00000X Contractor (Licence: IL 238000042) |
| Enumeration Date | 2010-06-03 |
| Last Update Date | 2010-06-03 |