| NPI | 1861701153 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NORMAN LEE DYKES Owner 337-234-1119 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: LA 05243R) |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: LA 02543R) |
| Enumeration Date | 2010-10-04 |
| Last Update Date | 2011-01-04 |