| NPI | 1366855876 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DEANN G LESANE Program Director 843-621-2696 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: SC 1042065) |
| Enumeration Date | 2014-06-03 |
| Last Update Date | 2014-06-03 |