| NPI | 1609315423 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JACLYN JOANN SULLIVAN Owner 516-662-1158 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: NY 001177) |
| Enumeration Date | 2017-02-13 |
| Last Update Date | 2017-02-13 |