| NPI | 1508231994 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WILLIAM VAN WURM Owner 228-818-0585 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208000000X Pediatrics |
| Additional Taxonomies | 261QM2500X Clinic/Center Medical Specialty (Licence: MS 20580) |
| 261QP2300X Clinic/Center Primary Care (Licence: MS 20580) | |
| Enumeration Date | 2015-12-10 |
| Last Update Date | 2017-01-19 |