| NPI | 1881052454 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WAYNE RUSSELL BONLIE President 410-560-7404 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: MD D0062606) |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2016-06-30 |