| NPI | 1144320052 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TOMMY LAVAUGHN RANDOLPH Md 386-755-1440 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME46235) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME51982) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2018-10-31 |