| NPI | 1043961550 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NICOLE N JACKSON Owner 678-727-8384 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service |
| Additional Taxonomies | 251S00000X |
| Enumeration Date | 2022-01-16 |
| Last Update Date | 2024-06-30 |