| NPI | 1366812224 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BREHONDA LEWIS-CUFF Owner/Operater 804-397-6109 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: VA 0701005787) |
| Additional Taxonomies | 305S00000X Point of Service (Licence: VA 0701005787) |
| Enumeration Date | 2015-10-04 |
| Last Update Date | 2015-10-05 |