| NPI | 1912372418 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LISA HAEUSER His 262-514-4322 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: WI 143860) |
| Enumeration Date | 2015-12-09 |
| Last Update Date | 2015-12-09 |