| NPI | 1104531425 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LONNIE LATRELL MOORE Mr 662-444-7273 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care |
| Additional Taxonomies | 261QI0500X Clinic/Center, Infusion Therapy |
| Enumeration Date | 2023-01-20 |
| Last Update Date | 2023-01-20 |