| NPI | 1346652641 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LATEAIRA JISHON PARKS Cna 1832-882-6348 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: TX 8580056) |
| Enumeration Date | 2014-05-21 |
| Last Update Date | 2014-05-21 |