| NPI | 1124195573 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRACY TEAGLE Office Manager 904-384-5385 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: FL 0042816) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: FL ME0018387) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2010-12-27 |