| NPI | 1063239911 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SUSAN C WILLIS Payer Credentialing Manager 937-999-3152 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2024-09-23 |
| Last Update Date | 2024-10-10 |