| NPI | 1831503911 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GINGER LYNNE MANOS Medical Doctor 850-398-2548 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2086S0129X (Licence: FL ME112123) |
| Additional Taxonomies | 2086S0129X (Licence: AL MD32127) |
| 2086S0129X (Licence: SC MD32487) | |
| 2086S0129X (Licence: GA 75309) | |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2023-05-26 |