| NPI | 1104176361 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHANTELL LANIECE DAVIS Senior Office Manager 702-706-7855 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: NV MIO195) |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2012-09-14 |