| NPI | 1134671514 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TAYLOR HICKMAN Office Assistant 757-366-0330 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: VA 0401411210) |
| Enumeration Date | 2016-11-01 |
| Last Update Date | 2016-11-01 |