| NPI | 1902094352 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TARA G DEATON Administrator 618-997-3400 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: IL 209000459) |
| Enumeration Date | 2007-10-11 |
| Last Update Date | 2007-10-11 |