| NPI | 1821698812 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LOIS R PETERSEN-KELLEY Business Manager 719-275-7650 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2020-10-28 |
| Last Update Date | 2022-06-07 |