| NPI | 1790152551 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RANDLLE DUMLAO Owner/ Manager 435-592-5815 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: UT 135666) |
| Enumeration Date | 2015-08-27 |
| Last Update Date | 2018-08-17 |