| NPI | 1972649630 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHANN DAVID FARLEY President 219-801-2665 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: IN 01060680A) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: WI 46905-20) |
| 261QP2300X Clinic/Center, Primary Care (Licence: CA A89493) | |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2024-03-26 |