| NPI | 1174868392 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JERAME TROY VANCIL Psr 510-967-5298 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: NV 0804464530) |
| Enumeration Date | 2012-11-28 |
| Last Update Date | 2012-11-28 |