| NPI | 1407902059 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ASHLEY LONG Credentialing/Enrollment Specialist 984-333-2741 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 305R00000X Preferred Provider Organization (Licence: NC 28064) | |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2021-12-08 |