| NPI | 1265593446 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CAROLYN LACY Icwp Case Manager 404-328-0999 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: GA 066110LGB) |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2020-08-22 |