| NPI | 1407396773 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KEVIN BLANKENSHIP Owner 681-238-5957 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: WV 19121) |
| Enumeration Date | 2017-03-06 |
| Last Update Date | 2017-03-06 |