| NPI | 1750689253 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MANITA YVETTE JOHNSON Director 980-200-3598 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Additional Taxonomies | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |
| Enumeration Date | 2011-03-08 |
| Last Update Date | 2011-03-08 |