| NPI | 1720469760 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOANNA HAZELL Manager, Provider Enrollment 857-307-0854 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: MA 262278) |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2015-06-16 |