| NPI | 1174198568 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AUDRA FICKEN Sr. Rcm Manager 855-408-1143 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2021-05-26 |
| Last Update Date | 2026-01-23 |