| NPI | 1407396294 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DEAVONTE J WILLIAMS CEO 567-315-6609 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: OH 4809149) |
| Enumeration Date | 2017-02-28 |
| Last Update Date | 2017-02-28 |