| NPI | 1104074319 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARTHA MOORE CLINTON Owner / Operator 662-560-4313 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QH0100X Clinic/Center Health Service (Licence: MS R672491) |
| Enumeration Date | 2008-08-29 |
| Last Update Date | 2023-03-07 |