| NPI | 1760827927 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ALLISON LYNN KRIEBEL Office Manager 267-770-1966 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2013-05-01 |
| Last Update Date | 2013-05-01 |