| NPI | 1841974748 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY WAGNER Provider 912-616-8033 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care |
| Additional Taxonomies | 261Q00000X Clinic/Center |
| 261QH0100X Clinic/Center, Health Services | |
| Enumeration Date | 2023-06-12 |
| Last Update Date | 2023-07-05 |