| NPI | 1861082901 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHAD BLALACK Manager 228-861-4218 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Additional Taxonomies | 261QH0100X Clinic/Center, Health Services |
| Enumeration Date | 2021-01-22 |
| Last Update Date | 2021-01-22 |