| NPI | 1164731626 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NIATIKQUA TIONSHAY GREEN Owner 352-401-7662 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: FL 000453000) |
| Enumeration Date | 2010-10-01 |
| Last Update Date | 2010-10-01 |