| NPI | 1457654568 |
|---|---|
| Former Legal Business Name | NONE |
| Entity Type | Organization |
| Authorized Contact | TRALADA W PURNELL Chaplain 330-000-0001 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: OH 305R00000X) |
| Enumeration Date | 2010-12-10 |
| Last Update Date | 2010-12-10 |