| NPI | 1043215643 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | FAITH Y TRADD Practice Administrator 386-822-9410 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: FL ME36213) |
| Enumeration Date | 2005-06-20 |
| Last Update Date | 2008-07-14 |