| NPI | 1407053549 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELLE HURST Aba Program Consultant 703-689-0019 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: na) |
| Enumeration Date | 2007-07-02 |
| Last Update Date | 2020-08-22 |