| NPI | 1912739772 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STANLEY FOMBUH Program Administrator 774-417-0932 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization |
| Enumeration Date | 2024-08-19 |
| Last Update Date | 2024-08-19 |