| NPI | 1982137105 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MIISHA MARIE OWENS Manager 314-372-9446 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: MO 001532409) |
| Enumeration Date | 2017-04-05 |
| Last Update Date | 2017-04-05 |