| NPI | 1942778923 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NIC WILDES Co Owner 617-203-7082 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X (Licence: MA 7118) |
| Additional Taxonomies | 261QM0801X |
| Enumeration Date | 2018-11-07 |
| Last Update Date | 2023-09-06 |