| NPI | 1609327246 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LISA DESIREE HARDING Health Administrator 731-602-9512 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: TN 1000000018834) |
| Enumeration Date | 2016-10-19 |
| Last Update Date | 2016-10-19 |