| NPI | 1578125209 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHARLEY MARIE BALBUENA AO 352-513-9265 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site |
| Enumeration Date | 2019-07-02 |
| Last Update Date | 2023-04-06 |