| NPI | 1952543191 |
|---|---|
| Other Name | TYPE 1 INDIVIDUAL PROVIDER |
| Entity Type | Organization |
| Authorized Contact | BRENA GIBSON Human Resources Director 301-439-7191 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: MD LC2381) |
| Enumeration Date | 2009-04-02 |
| Last Update Date | 2009-04-08 |