| NPI | 1770909160 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIFANI MEGAN REVELS LEE CEO,Lmt 863-443-3168 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty (Licence: FL MA65750) |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty (Licence: FL MA74492) |
| Enumeration Date | 2014-03-11 |
| Last Update Date | 2014-03-11 |