| NPI | 1265780720 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MEAGHAN E PHILLIPS Owner 386-314-3959 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: FL AP3008) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: FL MA38975) |
| Enumeration Date | 2012-08-15 |
| Last Update Date | 2017-05-04 |