| NPI | 1003195884 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DANTE TYLER Mgr Owner 540-891-4224 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: VA 1012540) |
| Enumeration Date | 2011-08-10 |
| Last Update Date | 2011-08-10 |