| NPI | 1104589258 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JAMES FORES Credentialing Specialist 239-424-1479 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2021-10-15 |
| Last Update Date | 2021-10-15 |