| NPI | 1992124754 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRYAN WELLS Owner 772-633-8814 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: FL CH10537) |
| Enumeration Date | 2014-04-09 |
| Last Update Date | 2014-04-09 |