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 |