| NPI | 1639430515 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DANIELLE MARIE LOPEZ Manager Credentialing/Enrollment 516-207-7936 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care |
| Enumeration Date | 2012-06-06 |
| Last Update Date | 2025-01-21 |