| NPI | 1861994204 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LYETTE ROSE BOUCHER President 239-948-1222 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL CH11313) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CH11148) |
| 363A00000X Physician Assistant (Licence: FL P.A.9104809) | |
| Enumeration Date | 2018-03-01 |
| Last Update Date | 2018-03-01 |