| Name | Value |
|---|---|
| PROVIDER TYPE | Other Service Providers |
| CLASSIFICATION | Specialist |
| AREA OF SPECIALIZATION | Research Study |
| STATUS | Inactive |
| DATE INACTIVATED | 2025-04-01 00:00:00 |
| VA CODE | V081904 |
| X12 CODE | 1744R1102X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253212 |
| EFFECTIVE DATE/TIME |
|