| NPI | 1508263120 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIM J WAHL Clerical 330-499-1494 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: OH 4574) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2014-11-25 |