| NPI | 1366815532 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NANNIE DELORS STARKE Service Facilitor 434-848-1013 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2015-11-10 |
| Last Update Date | 2015-11-10 |