| NPI | 1003980996 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KRISTY GLADDEN Provider Enrollment Manager 229-353-3402 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center (Licence: GA 137-180) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2023-11-21 |