| NPI | 1912440256 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEANNETTE C. WITHAM Clinical Supervisor 320-282-0112 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: MN 106H00000X) |
| Enumeration Date | 2016-11-18 |
| Last Update Date | 2016-11-18 |