| NPI | 1912211210 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HEATHER LYNN DIEDERICH Owner 802-434-6669 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: VT 006-0000998) |
| Enumeration Date | 2010-07-29 |
| Last Update Date | 2011-09-21 |