| NPI | 1174965727 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KENNETH GAUL Sole Member 631-473-7100 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: NY 5155205R) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2017-04-07 |