| NPI | 1205187424 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICAH JAMAL BENNETT Co Owner/President 845-594-2943 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: NY 992089481) |
| Enumeration Date | 2012-09-27 |
| Last Update Date | 2012-09-27 |