| NPI | 1134663024 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BERNARD SHEMAIAH COLLINS Executive Director 267-242-0939 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: PA BH001116) |
| Enumeration Date | 2016-12-12 |
| Last Update Date | 2016-12-12 |