| NPI | 1114562014 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DOUG MATTINGLY Owner 502-361-8801 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| Enumeration Date | 2019-11-14 |
| Last Update Date | 2020-01-30 |