| NPI | 1205288164 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHERWIN EUGENE BRYANT Compliance Officer 678-691-8239 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: GA 61430) |
| Enumeration Date | 2016-07-04 |
| Last Update Date | 2016-07-04 |