| NPI | 1053184622 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TERESA L PORTER Credentialing Manager 636-466-6452 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2023-11-06 |
| Last Update Date | 2023-11-06 |