| NPI | 1760202303 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LEEA JEANNIE WALTON Rcs Manager 336-515-7085 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine |
| Enumeration Date | 2024-10-16 |
| Last Update Date | 2025-06-24 |