| NPI | 1770961955 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JODIE CUNNINGHAM Owner 385-414-6267 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Additional Taxonomies | 305S00000X Point of Service |
| Enumeration Date | 2015-05-08 |
| Last Update Date | 2022-07-21 |