| NPI | 1902103617 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | PAMELA MICHELLE PHILLIPS Owner 318-617-5869 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: LA 10111532#MVA42) |
| Additional Taxonomies | 251S00000X |
| Enumeration Date | 2011-02-15 |
| Last Update Date | 2022-06-02 |