| NPI | 1750527875 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIMBERLY SUE CHILDRESS President 800-653-7017 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: KS 1702306) |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: NE 470) |
| 302F00000X Exclusive Provider Organization (Licence: MO 2005032056) | |
| Enumeration Date | 2008-12-18 |
| Last Update Date | 2008-12-18 |