| NPI | 1912127952 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIMOTHY MICHAEL BRADLEY Medical Director 618-355-0992 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QA1903X Clinic/Center, Ambulatory Surgical |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2020-08-22 |