| NPI | 1285080978 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CLAYTON GARY JOHNSEN Owner 909-886-3668 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: CA E4834) |
| Enumeration Date | 2016-05-11 |
| Last Update Date | 2022-06-20 |