| NPI | 1225368236 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | VIVIAN TYSON Asst. Director 678-793-4365 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Additional Taxonomies | 305S00000X Point of Service |
| Enumeration Date | 2010-01-14 |
| Last Update Date | 2010-01-14 |