| NPI | 1730997073 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHAVONDA L WILLIAMS Corporate Director 667-214-2507 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine |
| Enumeration Date | 2024-12-19 |
| Last Update Date | 2024-12-19 |