| NPI | 1922400563 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMANDA DEREMO Employer 608-449-1399 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: WI 318603) |
| Enumeration Date | 2014-09-25 |
| Last Update Date | 2014-09-25 |