| NPI | 1740648658 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JASCELYN ANN REVLAND Sole Member 214-598-0529 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: AZ LPC15253) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: TX 62500) |
| Enumeration Date | 2016-02-05 |
| Last Update Date | 2016-02-05 |