| NPI | 1992895106 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOSEPH A HICKS Dc 765-457-2273 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: IN 08002090A) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2020-08-22 |