| NPI | 1245609700 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHEVONTE LONG Owner 619-928-4299 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization |
| 302R00000X Health Maintenance Organization | |
| 305R00000X Preferred Provider Organization | |
| Enumeration Date | 2015-09-15 |
| Last Update Date | 2015-09-15 |