| NPI | 1164551503 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NISHMA HERRERA-DAYA Supervisor 800-201-8316 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: GA 002776) |
| Enumeration Date | 2007-03-03 |
| Last Update Date | 2020-08-22 |