| NPI | 1548819741 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANN SHAW Administrator 386-447-6615 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2025-07-01 |