| NPI | 1962763011 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BOLIVAR LUPERON Owner 404-903-8684 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: GA DN013214) |
| Enumeration Date | 2012-06-05 |
| Last Update Date | 2012-06-05 |