| NPI | 1699178723 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LA'TASHA DENISE LEE Independent Provider 979-451-3843 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2014-10-03 |
| Last Update Date | 2014-10-03 |