| NPI | 1700079571 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GLORIA L GILLESPIE Executive Vice President 800-645-1195 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2007-08-24 |
| Last Update Date | 2007-08-24 |