| NPI | 1992082788 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANDREA LO Executive Director 731-285-6499 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: TN 0298258) |
| Enumeration Date | 2011-11-08 |
| Last Update Date | 2012-12-26 |