| NPI | 1538534888 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MATTHEW DONNELLY Owner 239-223-0039 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: FL PA 9104124) |
| Enumeration Date | 2015-12-10 |
| Last Update Date | 2015-12-10 |