| NPI | 1497102230 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DIANNA F BADIPOUR Executive Director 262-513-9999 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2016-05-23 |
| Last Update Date | 2016-05-23 |