| NPI | 1407390800 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIMBERLY RUX Division Director 8552-024-5810 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: WI 17440000Z) |
| Enumeration Date | 2016-12-05 |
| Last Update Date | 2016-12-05 |