| NPI | 1720623770 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIMBERLY MOTOSICKY Credentialing Supervisor 866-287-2036 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2019-11-14 |
| Last Update Date | 2019-11-14 |