| NPI | 1881717544 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JIMMY B WALLACE Owner 580-436-9088 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: OK 8279) |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2020-08-22 |