| NPI | 1942961156 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | VALERIE FAZIO Organizer/Registered Agent 502-418-8561 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty |
| Enumeration Date | 2022-01-10 |
| Last Update Date | 2022-01-10 |