| NPI | 1245602069 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WILLIAM WALLACE Manager/Owner 904-990-3477 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2086S0122X Surgery, Plastic and Reconstructive Surgery (Licence: FL ME107749) |
| Enumeration Date | 2015-10-21 |
| Last Update Date | 2024-09-13 |