| NPI | 1629335096 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DONNA DENNERLEIN Assistant Program Director 209-723-6804 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2012-04-23 |
| Last Update Date | 2012-04-23 |