| NPI | 1871249524 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGIE MATTINGLY Provider Enrollment Manager 502-630-7425 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QR0400X Clinic/Center, Rehabilitation |
| Enumeration Date | 2022-02-22 |
| Last Update Date | 2022-02-22 |