| NPI | 1811166911 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TEMECHIUS LA'TRECE REYNOLDS Owner 985-288-7642 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Additional Taxonomies | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2008-02-22 |
| Last Update Date | 2008-02-22 |