| NPI | 1902000417 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRITTANY BOWMAN Cota 267-374-2681 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: PA 224Z00000X) |
| Enumeration Date | 2007-06-11 |
| Last Update Date | 2020-08-22 |