| NPI | 1396025854 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMY DENISE WILSON Owner 865-809-5304 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| 305S00000X Point of Service | |
| Enumeration Date | 2011-08-27 |
| Last Update Date | 2011-08-27 |