| NPI | 1124882949 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHANTE L JACKSON Payer Supervisor 267-207-7303 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 207Q00000X Family Medicine |
| Enumeration Date | 2024-02-12 |
| Last Update Date | 2024-02-21 |