| NPI | 1407430937 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LOIS R PETERSEN-KELLEY Business Manager 719-275-7650 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2021-05-11 |
| Last Update Date | 2021-05-11 |