| NPI | 1518402650 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELLE LEE JOHNSON Site Supervisor/Ma 928-472-4675 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2016-12-28 |
| Last Update Date | 2016-12-28 |