| NPI | 1962938894 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELLE HENNE President 863-401-4401 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty (Licence: FL ME121120) |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2017-06-06 |