| NPI | 1629358601 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHN L FUNDOCK Vice President 860-545-7188 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies |
| Additional Taxonomies | 213E00000X Podiatrist |
| 213ES0103X Podiatrist Foot & Ankle Surgery | |
| Enumeration Date | 2011-08-23 |
| Last Update Date | 2012-01-03 |