| NPI | 1992901672 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DIANE PITUCH IMMESBERGER Administrative Assistant 928-514-8602 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist |
| Additional Taxonomies | 305S00000X Point of Service |
| Enumeration Date | 2007-06-21 |
| Last Update Date | 2018-10-29 |