| NPI | 1104642354 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHAWNA BAXTER Provider Enrollment Specialist 870-257-5118 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM1300X Clinic/Center Multi-Specialty |
| Enumeration Date | 2024-12-03 |
| Last Update Date | 2024-12-03 |