| NPI | 1104229137 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CARALOTTA M. BLACKWELL Mainstay/Owner 682-215-8165 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2014-10-05 |
| Last Update Date | 2020-02-05 |