| NPI | 1083887434 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WAYNE LEVONNE BURCH Executive Director 704-345-2032 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2008-04-08 |
| Last Update Date | 2008-04-08 |