| NPI | 1154671824 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHELIA TICE Provider/Manager 662-534-8780 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: MS R857901) |
| Enumeration Date | 2012-09-10 |
| Last Update Date | 2013-06-18 |