| NPI | 1104466671 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANA BUSH Credentialing Specialist 479-437-3449 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2020-01-13 |
| Last Update Date | 2023-12-19 |