| NPI | 1063521250 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JAMES RYAN MOORMAN Owner 229-241-8925 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: GA 007773) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2021-05-19 |